Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions∗ ()
- ↵∗Address correspondence to:
Dr. Spencer B. King III, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
For those of us who still think of educational levels as the number of years in school, semester hours taken, or post-graduate degrees accumulated, we have to realize that there is a major movement in higher education toward “competency-based education.” The word “competency” seems to be used in many ways, and as it applies to physicians and future physician training, perhaps it is worthwhile for us to reflect on what is meant by the developers of educational systems. If someone asks me whether to see a specific doctor, and I respond, “Well, he is competent,” I am not sure I have provided a ringing endorsement. Competence in this context seems to be a qualitative measure that requires some modification, such as “highly.” As I look at several definitions of competence-based education, I read a more dichotomous measure of the ability to know or do something without much definition of where the bar is set for that performance. It would appear that just south of competence is incompetence. Does competence mean meeting minimal standards, or are there gradations in competence? Is this important in cardiology?
The American Board of Medical Specialists, as some of you are aware, has instituted milestones to be achieved in our graduate medical education. As far as cardiology and interventional cardiology are concerned, we are all aware that the American Board of Internal Medicine provides an opportunity to sit for an examination that will attempt to measure the competence of the candidates for initial or subsequent recertification. When we began the interventional cardiology boards 15 years ago, we assumed that trainees would need a certain amount of time and a certain volume of experience to achieve a level of training that would earn them the designation of cardiologist or interventional cardiologist. As our field has evolved, new knowledge and new skills have been added at a rapid pace, so the definition of a competent interventional cardiologist may have become more difficult.
In the next month or so, a new COCATS training document for cardiology will be released and will be consistent with the competency-based education mandated by the American Board of Medical Specialists. Competencies will be set up in 6 domains: 1) medical knowledge; 2) patient care and procedural skills; 3) systems-based practice; 4) practice-based learning and improvement; 5) professionalism; and 6) interpersonal and communication skills. Within the 3-year training program, the maximum time point for achieving these competencies will be identified. Various competencies have been well thought out and vetted through many reviews. The difficult part will be in judging whether the fellow has achieved competence in these specific requirements. Formally, we could have judged fellows rather subjectively as being “good” or “super,” or perhaps more quantitatively on a 10-point scale for overall performance, but this would leave the judgment of whether the person is competent in various areas unknown. Rating trainees on a 10-point scale usually resulted in lumping people together at the upper end with all fellows being, to paraphrase Garrison Keillor, “above average” (1). The ACC has developed training tools for program directors and faculty to understand this new world of competence-based education. Levels of competence have been developed for various milestones. Here, we begin to see how a trainee could be judged at various points in training on a 5-point scale: level 1—critical deficiencies; level 2—early learner; level 3—advanced/improving; level 4—ready for unsupervised practice; and level 5—aspirational. If this more nuanced measure of competence is applied to the various milestones, you can see that a fellow early in training entering the catheterization laboratory would be expected to have critical deficiencies, although this would not be a damning assessment of the fellow’s first day in the catheterization laboratory. However, at what point in training will the fellow achieve the designation of level 4 and be ready for unsupervised practice, so that the trainee can “consistently and effectively perform and interpret all aspects of cardiac catheterization procedure; constantly recognize appropriate indications and individual patient risk; and is able to manage complications that occur during or as a result of the procedure.” What if a fellow is judged to have this level of competence after being exposed to 100 catheterization procedures, whereas another fellow has not achieved this level after 300 procedures? Will the patient mix play an important role in this competency area of patient care, and will the quality of the supervision and mentoring also play a role? How will the supervising faculty adjudicate what level of competence a trainee has achieved throughout the training process for all the many milestones that have been defined? This sounds like a daunting task, but the ACC has instituted a program including webinars to help training directors understand and deal with these new requirements. It will be interesting to see how these changes will be implemented, and I am certain that this will be an iterative process, in which a great deal will be learned from the process itself.
Whereas the COCATS document is to cover the 3-year cardiology program, training documents for interventional cardiology have not been developed. There is a process to evaluate electrophysiology training with the potential of moving to a 2-year training requirement. As I think about competence-based education, which is moving away from time and volume requirements toward achievement-defined competencies, I see a bit of schizophrenia in terms of how much time will be required to accomplish those goals. I do not think in the near term we are going to totally get away from time commitment and volume on the basis of prior experience, but competency-based education is a laudable goal. At the present time, the process established for cardiology is being applied to cardiology subspecialties as well, but this may require significant modification for interventional cardiology given the potential for branching directions in training toward structural heart disease, peripheral vascular disease, and so forth.
For those who set standards in education and training, standardization is an obvious goal. Achieving competence is a worthy goal, and quantification of the degree of competence is something we all expect. As the COCATS document for cardiology is rolled out, we should give thought to how those core competencies will need to be modified for interventional cardiology training and whether that training needs to transform with additional milestones that will reflect the various competencies needed to address the myriad of circumstances now within the realm of our discipline. There will be a lot of heavy lifting for training program directors, and they will be the ones in the forefront of molding the educational process for our continuously evolving subspecialty.
- American College of Cardiology Foundation
- ↵BrainyQuote. Garrison Keillor quotes. Available at: http://www.brainyquote.com/quotes/quotes/g/garrisonke137097.html. Accessed December 30, 2014.