Best practices in teaching echocardiography to cardiology fellows: a review of the evidence.

BACKGROUND: Best practices in the teaching of performance and interpretation of echocardiography to cardiology fellows are unknown, and thus, it has traditionally been performed through an apprenticeship model. This review summarizes the existing literature describing evidence-based teaching of echocardiography. METHODS: A comprehensive search of multiple scientific and educational databases included prospective studies describing an educational intervention for teaching echocardiography to physicians. A total of 288 articles were retrieved, and 10 articles were included in our review. The Medical Education Research Study Quality Instrument (MERSQI), a validated rubric designed to measure the methodological quality of educational research, was used to assign a comprehensive score to each paper. RESULTS: The articles were categorized by educational themes as follows: focused curriculum-based training, simulation, and assessment of competency. Individual study MERSQI scores varied from 8 to 13 (mean 10.55) on a scale of 18 points. The distribution of each group's median score (focused curriculum-based training 11.64; simulation 12.92; assessment of competency 9.39) was analyzed using boxplots with a 95% confidence interval. The median MERSQI score for the assessment of competency group was significantly lower than the others. CONCLUSIONS: A review of the data exploring best practices in teaching echocardiography shows only limited effects describing the curricular and assessment components of an overall educational system, rather than one-on-one clinical teaching. Future papers should explore application of point-of-care teaching and the impact of interventions on patient outcomes.

Mind the Gap: Representation of Medical Education in Cardiology-Related Articles and Journals.

BACKGROUND: Cardiology fellowship programs are at the interface of medical education and the care of patients suffering from the leading cause of mortality in the United States, yet there is an apparent lack of research guiding the effective education of fellows. OBJECTIVE: We sought to quantify the number of publications in cardiology journals that pertained to the education of cardiology trainees and the number of cardiologists participating in education research. METHODS: For the period between January and December 2012, we cataloged cardiology-specific and general medical/medical education journals and sorted them by impact factor. Tables of content were reviewed for articles with an educational focus, a cardiology focus, or both. We recorded the authors' areas of medical training, and keywords from each cardiology journal's mission statement were reviewed for emphasis on education. RESULTS: Twenty-six cardiology journals, containing 6645 articles, were reviewed. Only 4 articles had education themes. Ten general medical and 15 medical education journals contained 6810 articles. Of these, only 7 focused on medical education in cardiology, and none focused on cardiology fellowship training. Among the 4887 authors of publications in medical education journals, 25 were cardiologists (less than 1%), and among the 1036 total words in the mission statements of all cardiology journals, the term "education" appeared once. CONCLUSIONS: Published educational research is lacking in cardiology training, and few cardiologists appear to be active members of the education scholarship community. Cardiology organizations and academic journals should support efforts to identify target areas of study and publish scholarship in educational innovation.

The Essential Role of Educator Development: 10 Years of the ACC Emerging Faculty Program.

The American College of Cardiology Emerging Faculty program was developed in 2005 to promote a systematic approach to "educate the educators" through training and mentorship. A primary focus of the program is the biennial Teaching Skills Workshop, which has had 130 participants since its inception and is focused on the concepts of effective adult learning, curriculum design, and optimization of presentation skills. A survey of participants (80 respondents of 130 total participants) found that the majority stated that participation in the program had a large impact on their ability to apply instructional design principles (49%) and present in face-to-face settings (47%), and it had a moderately large to large positive impact on their personal careers. Thus, the Emerging Faculty program combines several elements of the College's strategic plan in a single program that provides member value to early career professionals and sustained benefit for the cardiovascular community and patients.

Defining characteristics of early adopters of multimodality cardiovascular imaging.

BACKGROUND: The prototype for the cardiovascular imager has evolved to necessitate some degree of competency in multimodality imaging (MMI)-defined as expertise in at least 2 of the 4 modalities (echocardiography [ECHO], nuclear cardiology [NUC], cardiovascular computed tomography [CCT], and magnetic resonance [CMR]). Uncertainty exists about the effects of this change. METHODS: Information detailing the current totals of board-certified practitioners in MMI was collected and organized into groups of 1, 2, and 3 modalities. A randomized stratified sample of names was obtained to identify a representative 10% of each group. Those names were cross-referenced online with information from state medical boards, faculty rosters of academic medical centers, and physician tracking Websites. RESULTS: There are a total of 2209 board-certified MMI practitioners (2 modalities = 1885, 3 modalities = 324) and 6450 single-modality imagers in the United States. Of those sampled, 98.9% were cardiologists, 31.3% were at academic medical centers and mean time from medical school graduation was 17.75 years. MMI practitioners were more likely to have graduated from medical school more recently (P < 0.0001) and to be trained cardiologists (P = 0.003) than those who practice in a single modality. There was a nonsignificant trend toward MMI being practiced more commonly in an academic setting (P = 0.38). CONCLUSION: Board-certified specialists in MMI tend to be younger cardiologists than those engaged in single-modality cardiac imaging. There are few advanced (3 modality) MMI practitioners in the United States.

Chemotherapy-induced takotsubo cardiomyopathy.

Stress cardiomyopathy, also known as takotsubo cardiomyopathy, is a rapidly reversible form of acute heart failure classically triggered by stressful events. It is associated with a distinctive left ventricular contraction pattern described as apical akinesis/ballooning with hyperdynamic contraction of the basal segments in the absence of obstructive coronary artery disease. The traditional paradigm has expanded to include other causes, in particular chemotherapeutic drugs. The literature increasingly suggests an association between cancer, chemotherapeutic drugs, and stress cardiomyopathy. Chemotherapy-induced takotsubo cardiomyopathy is a relatively new phenomenon, but one that merits detailed attention to the elucidation of possible mechanistic links.

Successful efforts to increase diversity in a cardiology fellowship training program.

BACKGROUND: A large volume of literature has documented racial disparities in the delivery of cardiovascular care in the United States and that decreased access to procedures and undertreatment lead to worse outcomes. A lack of diversity among physicians is considered to be a major contributor. The fellowship training program in cardiovascular medicine at The Ohio State University Medical Center had never trained a fellow from a minority group underrepresented in medicine (URM) before 2007. INTERVENTION: In 2005, the fellowship made it a priority to recruit and match URM candidates in an effort to address the community's lack of diversity and disparities in cardiovascular care. METHODS: Program leaders revised the recruitment process, making diversity a high priority. Faculty met with members of diverse residency programs during visits to other institutions, the focus of interview day was changed to highlight mentorship, additional targeted postinterview communications reached out to highly competitive applicants, and a regular mentoring program was constructed to allow meaningful interaction with URM faculty and fellows. RESULTS: Since these changes were implemented, the program has successfully matched a URM fellow for 5 consecutive years. Such candidates currently make up 4 of 16 total trainees (25%) in the fellowship in cardiovascular medicine. CONCLUSIONS: The cardiovascular medicine fellowship training program at The Ohio State University was able to revise recruitment to attract competitive URM applicants as part of a concerted effort. Other educational programs facing similar challenges may be able to learn from the university's experiences.

Impact of 64-slice multidetector computed tomography on other diagnostic studies for coronary artery disease.

BACKGROUND: The clinical role of cardiovascular multidetector computed tomography (CT) remains in evolution, and application varies widely. Understanding its impact on the utilization of other cardiovascular diagnostic modalities could help define best practices. METHODS: Utilization of diagnostic testing was examined for the initial 1053 consecutive patients who underwent cardiovascular multidetector CT examinations after scanner installation in 2005. Yearly procedural volumes in the invasive catheterization and noninvasive stress laboratories were assessed before and after the introduction of multidetector CT. RESULTS: Ninety-one patients (8.6%) of the 1053 required invasive diagnostic catheterization; of these, nearly half subsequently underwent percutaneous or surgical intervention. Diagnostic catheterization and interventional volumes maintained their previous rates of annual increase, while the volume of stress testing decreased once multidetector CT became available. CONCLUSIONS: The major impact of multidetector CT in initial cardiovascular practice is on the need and frequency of stress testing, with far less impact on utilization of cardiac catheterization and coronary interventions.

Methods of teaching and evaluating electrocardiogram interpretation skills among cardiology fellowship programs in the United States.

BACKGROUND: This study examines the methods used by cardiology training programs within the United States to teach electrocardiogram (ECG) interpretation and prepare fellows for the American Board of Internal Medicine board examination. METHODS: A link to an 18-question Web-based survey was electronically mailed to 198 fellowship directors in the United States. RESULTS: The response rate was 45%. Most participating programs were university hospitals or affiliates (77%) and of moderate size (at least 11 total fellows [72%]). Programs were coordinated by senior (68%) general (60%) cardiologists. Only 42% of the programs performed formal testing. The American Board of Internal Medicine answer sheet was used by most faculty (92%) when teaching ECG interpretation. CONCLUSIONS: Teaching of ECG interpretation varies among US fellowship programs. Coordination of curricula is performed by senior faculty, likely reflecting a trend toward subspecialization and dilution of ECG expertise among younger faculty. Future endeavors should focus on curriculum standardization with regular competency assessment.

Logistical barriers to career development in academic cardiovascular multimodality imaging-challenges for future mentors.

OBJECTIVES: To define the practical logistics involved in the training, maintenance of technical proficiency, credentialing, and board certification for academic multimodality cardiovascular imaging specialists. BACKGROUND: Trends in cardiovascular imaging reflect a new paradigm emphasizing expertise in all four major modalities. In order to become a faculty member responsible for educating fellows-in-training, academic imagers face a daunting process with a shortage of senior mentors. METHODS: Detailed information describing fellowship training, the aggregate monthly volume of publications, credentialing, continuing medical education requirements, and board certification were obtained for each subspecialty area of cardiovascular medicine from various online sources. RESULTS: Compared with other subspecialty areas of cardiovascular medicine, multimodality imaging requires more reading (44% more pages of publications), more continuing medical education hours (300-467% more), and additional board certification (three boards instead of one or two). CONCLUSIONS: Achieving competency in multimodality imaging is difficult and expensive in 2009, but still possible. To advance the career development of current academic faculty in this area, future emphasis should be on streamlining training, accreditation, and board certification requirements while focusing on research proving the value of integrated imaging in cardiovascular disease.

Newly diagnosed arrhythmogenic right ventricular dysplasia in an octogenarian.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is thought to be a disease of the young, with the majority of newly diagnosed patients under 40 years of age. Establishing this diagnosis in elderly patients may be challenging, and a few reports exist of patients older than 70 years diagnosed with ARVD/C at autopsy. We report the case of an octogenarian with antemortem newly diagnosed ARVD/C. This case report represents the oldest patient to date to have a newly established diagnosis of ARVD/C and highlights the difficulty in making the diagnosis in the elderly.

Aortic pathophysiology by cardiovascular magnetic resonance in patients with clinical suspicion of coronary artery disease.

PURPOSE: To correlate cardiovascular magnetic resonance (CMR)-based measurement of aortic pulse wave velocity (PWV) with serum markers for atherosclerosis and plaque burden in the thoracic aorta. METHOD: Individuals with risk factors for coronary atherosclerosis underwent CMR pulse wave velocity examination of the descending thoracic aorta and computed tomography for coronary calcium scoring. Inversion recovery images allowed quantification of aortic plaque. Serum lipids and c-reactive protein levels were measured. RESULTS: Mean PWV did not correlate with presence of aortic plaque (p = 0.55). Subgroup analysis showed no significant correlation with PWV and total plaque. PWV and pulse pressure correlated (PP) (R2 0.38, p = 0.0003), but PWV and other predictor variables did not. Total plaque area correlated with aortic diameter (p = 0.0066). CONCLUSIONS: In patients with suspected coronary artery disease, aortic pulse wave velocity reflects increased aortic stiffness demonstrated by elevated pulse pressure, but does not directly correlate with aortic plaque or serum markers for arterial disease.