The society for cardiovascular angiography and interventions structural heart disease early career task force survey results: Endorsed by the society for cardiovascular angiography and interventions

Over the last decade, structural heart disease interventions have emerged as a new field in interventional cardiology. Currently, the Accreditation Council for Graduate Medical Education accredited interventional cardiology fellowship programs in the United States provide high‐quality and well established training curriculum in coronary and peripheral interventions, but training in structural interventions remains in its infancy. The current survey seeks to collect relevant information and assess the opinion of interventional cardiology program directors in ACGME‐accredited institutions that are actively involved in structural interventional training. Our study describes the actual number of structural procedures performed by interventional cardiology fellows in ACGME‐accredited programs, the form of the structural training today and the suggestions from program directors who are actively trying to integrate structural training in the interventional cardiology fellowship programs. © 2012 Wiley Periodicals, Inc.     

Variations in adult congenital heart disease training in adult and pediatric cardiology fellowship programs

OBJECTIVES: The purpose of this study was to evaluate adult congenital heart disease (CHD) training among U.S. cardiology fellowship programs. BACKGROUND: Although training recommendations for caring for adults with CHD exist, the educational patterns and numbers of specialists remain unknown. METHODS: We surveyed U.S. directors of 170 adult cardiology and 45 pediatric cardiology (PC) fellowship programs. Adult program surveys contained 1 single-response and 10 multiple-choice questions; pediatric program surveys contained 1 single-response and 13 multiple-choice questions. RESULTS: Ninety-four adult cardiology fellowship directors (55%) and 34 PC directors (76%) responded. Of adult programs, 70% were in university hospitals and 40% were associated with PC groups. Those with PC-affiliation had more adult CHD clinics (p < 0.02) and more adult CHD inpatient (p < 0.02) and outpatient (p < 0.002) visits than those without PC affiliation. Most PC programs were in children's hospitals (38%) or children's hospitals within adult hospitals (50%). Eighty-two percent had associated adult cardiology programs. Pediatric programs followed adult CHD patients in various care settings. Over one-third of adult and pediatric programs had < or = 3 lectures annually regarding adult CHD. Nine adult and 2 pediatric programs offered adult CHD fellowships, and only 31 adult and 11 pediatric fellows pursued advanced CHD training in the last 10 years. CONCLUSIONS: Adult CHD didactic and clinical experiences for cardiology fellows vary widely. Few programs offer advanced CHD training, and the number of specially trained physicians is unlikely to meet projected workforce requirements. Adult cardiology programs with PC affiliation have increased CHD experience and might provide good educational models.     

Current status of preventive cardiology training among United States cardiology fellowships and comparison to training guidelines

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.     

SCAI expert consensus statement for advanced training programs in pediatric and congenital interventional cardiac catheterization

Pediatric and Congenital Interventional Cardiology is the practice of catheter‐based techniques that improve cardiac physiology and circulation through the treatment of heart disease in children and adults with congenital or acquired heart defects. Over the last decade, and since last published training guidelines for pediatric cardiac catheterization and interventional cardiology were published in 2005 [1] the field of Pediatric and Congenital Cardiac Catheterization has evolved into a predominantly interventional discipline. As there is no sub‐specialty certification for interventional cardiac catheterization in pediatrics, the Congenital Heart Disease Committee of the Society of Cardiovascular Angiography and Interventions has put together this consensus statement for advanced training in pediatric and congenital interventional cardiac catheterization. The statement puts forth recommendations for program infrastructure in terms of teaching, personnel, equipment, facilities, conferences, patient volume and trainee assessment. This is meant to set a standard for training programs as well as giving applicants a basis on which to judge and compare programs. © 2014 Wiley Periodicals, Inc.     

Diversity among transplant surgery fellowship program directors: a call to action

BackgroundThe diversity among general surgery residency, HPB and other fellowship program directors has been previously analyzed. However, the diversity in abdominal transplant surgery fellowship program directors remains unknown.MethodsAbdominal transplant fellowship programs and the corresponding program directors were identified from the American Society of Transplant Surgeons website. Demographic and training information for the members was compiled through internet searches and analyzed.Results72 program directors were included. 83.33% were male. 63.9% were non-Hispanic White, 25% were Asian, along with 5.56% Hispanic and Black each. Male program directors were more likely to be Associate Professor (p = 0.041), while females were more likely to be Assistant Professor (p = 0.021). 66% of female program directors were non-Hispanic White.ConclusionTransplant surgery fellowship programs are primarily led by male and non-Hispanic White surgeons. Female representation as leaders is on par with their membership in the transplant surgery workforce. There is a deficiency of both male and female underrepresented minorities in program director positions.     

The current situation in training and education of assistant staff in interventional cardiology

The number of heart catheter laboratories in Germany has been increasing for years. While there are general training regulations for cardiologists, nothing comparable exists for the assistant staff in interventional cardiology. Qualification is settled within the department. Aim of this study was the determination of the demand in general training and qualification courses. All heart catheter laboratories in North Rhine-Westphalia were questioned. Assistants (227) and medical directors (43) from 48 laboratories (54.0% returns) answered. Of the assistants 59.1% were qualified nurses, 28.2% consulting room assistants, and 10.1% medical technicians. Most of them were female (85.0%); the average age was 34.3 years. Of the assistants 73.1% were not trained in their current hospital or practice. Before their occupation in cardiac catheterization, 51.8% worked in nursing and 17.6% in ECG, sonography, etc. None of the 227 assistants was still in training at the time of questioning although 68.3% of the hospitals and practices accept trainees. Nine out of ten laboratories offer inhouse qualification, mainly in radiation protection (82.1%) and medical fields (66.7%), and 85.3% of the assistants have already attended these. Of the medical directors 90.0% and 99.2% of the assistants consider general training and qualification courses to be necessary. When asked for important fields for training programs, the assistant staff mentions "medicine" (77.6%), "examination assistance" (67.0%), and "EDP" (60.4%), while the medical directors place importance on "quality management" (89.2%) and "radiation protection" (86.5%). The job market for assistants the interventional cardiology is still good: 14.3% of the laboratories plan to take on new employees, 61.9% want to keep their number of assistants. The share of part-time work is low (16.8%). The momentary qualification and training of assistant staff in interventional cardiology does not match the demand. General programs for trainees with universally applicable teaching objectives and examination regulations are necessary.     

Results of the society of cardiac angiography and interventions survey of physicians and training directors on procedures for structural and valvular heart disease

Background: Minimal information is available on the number and type of procedures being performed for structural and valvular heart disease, the physicians who perform these procedures, and on the training requirements for this emerging field. Methods: Surveys were performed using an online survey of members of the Society of Cardiac Angiography and Interventions (SCAI), including its Council on Structural Heart Disease and the Congenital Heart Disease Committee. The responses of 107 US‐based interventional cardiologists were analyzed. A second questionnaire of a purposive sample of 10 training directors of US interventional cardiology programs was also performed. Results: Although many procedures (e.g., transseptal puncture, PFO, and ASD closure) are commonly performed by most respondents, others are limited to a significant minority of respondents (e.g., alcohol septal ablation, transcatheter valve repair, and implantation). In addition, the number of procedures performed varies greatly as does the training directors' estimate of the number necessary to gain proficiency. There is no single method being used to gain the requisite skills. A number of factors that limit the more widespread growth of this field were identified. Conclusions: The field of intervention for structural and valvular heart disease is new, growing rapidly, and will require a core knowledge base and new didactic methods. The cardiovascular community will be challenged to devise new training standards and credentialing approaches to serve interventionalists interested in this field. © 2010 Wiley‐Liss, Inc.     

Qualit?tsverbesserung von Koronardiagnostik und -intervention durch ?Virtual-Reality��-Simulation

Currently, more than 800,000 diagnostic procedures and 300,000 percutaneous coronary interventions are performed annually in 556 catheter laboratories in Germany. These numbers document the importance of training programs in interventional cardiology. However, this need is in sharp contrast to the time constraints for continuing medical education in Germany due to personnel and financial restrictions. A possible solution for this dilemma could be new training programs which partially supplement conventional clinical training by simulation-based medical education. Currently five virtual reality simulators for diagnostic procedures and percutaneous coronary interventions are available. These simulators provide a realistic hands-on training comparable to flight simulation in aviation.The simulator of choice for a defined training program depending on the underlying learning objectives could either be a simple mechanical model (for puncture training) or even a combination of virtual reality simulator and a full-scale mannequin (for team training and crisis resource management). For the selection of the adequate training program the basic skills of the trainee, the learning objectives and the underlying curriculum have to be taken into account. Absolutely mandatory for the success of simulation-based training is a dedicated teacher providing feedback and guidance. This teacher should be an experienced interventional cardiologist who knows both the simulator and the selected training cases which serve as a vehicle for transferring knowledge and skills.In this paper the potential of virtual reality simulation in cardiology will be discussed and the conditions which must be fulfilled to achieve quality improvement by simulation-based training will be defined.     

The training for and practice of percutaneous transluminal coronary angioplasty: results of two surveys

In order to gain understanding of how percutaneous transluminal coronary angioplasty (PTCA) is taught and practiced in the United States, two questionnaires were devised to survey all adult cardiology training programs and all adult cardiac catheterization laboratories in this country. Of the 184 programs that responded to the training questionnaire, 102 (55%) teach PTCA, usually in the form of fellowship training and especially as a specialized year, and less commonly in the form of a preceptorship. Though many programs expose trainees to an adequate number of cases as defined by the program directors, at least 37% do not. Of 388 laboratories responding to the practice questionnaire, 74% perform PTCA. The total number of PTCA's in this country seems to be doubling yearly, but many laboratories do relatively few cases per year, and 79% of physicians doing PTCA do fewer than one case per week. Average laboratory success rate for PTCA is in the range of 80-85%. Though there is now a proliferation of PTCA training programs, 93% of those practicing angioplasty are self- or preceptor-trained, and have not learned the procedure as part of a fellowship.     

Imaging: New Frontiers in Vascular Training

Advances in medical imaging have redefined the practice of vascular surgery. Current training programs for vascular surgery do not incorporate formal training in vascular imaging other than in duplex ultrasound when a physician is undergoing the vascular interpretation certification process. Yet imaging modalities and techniques have grown exponentially in the adjacent fields of interventional radiology, interventional and diagnostic cardiology, and neuroradiology, so much so that advanced imaging fellowships have been established in these fields. This article reviews the current state of vascular imaging training, identifies gaps in the current training regimen, and proposes an advanced vascular imaging fellowship for the future.     

Left internal mammary artery side branch intervention in the management of coronary steal syndrome following coronary artery bypass grafting

Social media allows interventional cardiologists to disseminate and discuss research and clinical cases in real-time, to demonstrate and learn innovative techniques, to build professional networks, and to reach out to patients and the general public. Social media provides a democratic platform for all participants to influence the conversation and demonstrate their expertise. This review addresses the use of social media for these purposes in interventional cardiology, as well as respect for patient privacy, how to get started on social media, the creation of high-impact social media content, and the role of traditional journals in the age of social media. In the future, we hope that interventional cardiology fellowship programs will incorporate social media training into their curricula. In addition, professional societies may adapt to the rapid dissemination of data on social media by developing processes to update guidelines more rapidly and more frequently.     

Teaching Geriatric Fellows How to Teach: A Needs Assessment Targeting Geriatrics Fellowship Program Directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine‐question survey adapted from a 2001 survey issued to residency program directors inquiring about residents‐as‐teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6‐week period. Of 144 ACGME‐accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e‐mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.     

National Study of Internal Medicine Manpower. XII. The future of graduate medical education in internal medicine: what do program directors predict?

The 1985-1986 National Study of Internal Medicine Manpower asked directors of residency and fellowship programs about their plans to change the size of their programs in the near future. The vast majority (71% to 76%) of the directors expected their programs to remain about the same size for the next couple of years. For fellowship directors, this reflects a decline in the number planning to increase their program size since 1976-1977 from 32% to 18%. Directors of programs that are principal affiliates of medical schools are more likely to plan a decrease, while Veterans Administration directors are more likely to plan an increase in program size. The reason residency directors cited most frequently as important to their plans to increase program size was a perceived shortage of internists. Fellowship directors most frequently cited the need for fellows in clinical research. Stipend availability was the most important factor that influenced plans to decrease program size. Overall, residency and fellowship directors planned to increase the size of their programs around 1%. Program directors and others in the internal medicine community should consider how they can change the stipend availability, admissions criteria, and other incentives to channel trainees into the areas of greatest potential need and demand for the profession.     

Evaluation of clinical competence in cardiovascular disease

The American Board of Internal Medicine has called on directors of cardiology training programs to establish systems to evaluate, document and substantiate those components of overall clinical competence considered essential for certification in the subspecialty. Many of these can be assessed only by repeated direct observations. In particular, proficiency is now required in advanced cardiac life support including cardioversion, electrocardiography (including ambulatory electrocardiographic monitoring) and exercise testing, echocardiography, insertion of arterial lines and right heart catheterization (including insertion of temporary pacemakers). The goal of this expanded evaluation program is to ensure that the public and the profession can identify, through certification, physicians with demonstrated excellence in cardiovascular disease.     

Paediatric cardiology programs in countries with limited resources: how to bridge the gap

Establishing paediatric cardiology service in a country with limited resources like Sudan is a challenging task.A paediatric cardiac team was formed then the services in different disciplines were gradually established. Echocardiography (echo) clinics were founded in tertiary and peripheral hospitals. Cardiac catheterization (cath) was established at the Sudan Heart Centre (SHC) in 2004 and over 400 procedures had been performed including interventional catheterization like pulmonary valve dilatation, patent ductus arteriosus and atrial septal defect device closure.Congenital heart surgery started in 2001, currently 200 cases are done each year including closed procedures as well as open heart procedures for patients weighing more than 8 kg. Cardiology-cardiac surgery as well as adult congenital heart disease meetings were held and contributed positively to the services. The cardiology-cardiac surgery scientific club meeting was founded as a forum for academic discussions. A fellowship program was established in 2004 and included seven candidates trained in paediatric cardiology and intensive care. Two training courses had been established: congenital heart disease echo and paediatric electrocardiogram interpretation. Links with regional and international cardiac centres had important roles in consolidating our program.Significant obstacles face our service due to the small number of trained personnel, high cost of procedures, the lack of regular supplies and lack of cardiac intensive care facilities for young infants.Bridging the huge gap needs extensive official as well as non-governmental efforts, training more staff, supporting families and collaboration with regional and international centres.     

A Deeper Look at the Small Bowel: Training Pathways in Video Capsule Endoscopy and Device-Assisted Enteroscopy

Background

Although there are guidelines for video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), little is known about fellowship training in these technologies.

Aims

The aims were to better characterize current small bowel endoscopy training in 3-year GI fellowship programs and 4th-year advanced endoscopy programs in the U.S.

Methods

We developed an online multiple-choice survey to assess current GI fellowship program training in small bowel endoscopy. The survey was distributed via email to GI fellowship program directors in the U.S.

Results

Of the 168 program directors contacted, 59 responded (response rate?=?35.1%). There was no statistically significant difference in the availability of VCE or DAE between respondents and non-respondents. VCE training was universally available in 3-year training programs, with 84.8% (50/59) requiring it for fellows. The majority of 3-year GI fellows graduated with independence in VCE: 83.1% (49/59) of programs reported “most” or “all” graduates were able to read independently. DAE techniques were available in 86.4% of training programs (51/59). Training in DAE was more limited and shared between 3-year and 4th-year programs: 12.1% (7/58) of 3-year programs required training in DAE and 22.9% (8/35) of 4th-year programs required training in DAE.

Conclusions

Training in VCE is widely available in U.S. GI fellowship programs, although programs have different ways of incorporating this training into the curriculum and of measuring competency. While DAE technology was available in the majority of programs, training was less frequently available, and training is shared between 3-year fellowship programs and 4th-year advanced endoscopy programs .

     

Actualización en cardiología intervencionista

This article contains a detailed review of the most important studies on interventional cardiology reported in either publications or presentations. With regard to coronary interventions, ST-elevation myocardial infarction is highlighted because of the ongoing substantial expansion in primary angioplasty programs. Drug-eluting stents, especially new-generation stents, continue to be the focus of numerous studies. Clinical outcomes in diabetic patients with left main coronary artery or multivessel disease are also dealt with by much research. In addition, intracoronary diagnostic techniques, particularly optical coherence tomography, is reviewed. Finally, there is increasing interest in the percutaneous treatment of structural heart disease, particularly percutaneous aortic valve implantation     

Interventional cardiology in Israel at 2005 - state of practice

OBJECTIVE: To assess the current practice of interventional cardiology in Israel. METHOD: Under the auspices of the 'Working group of interventional cardiology' of the 'Israel Heart Society,' a questionnaire regarding the practice of interventional cardiology sent to directors of interventional cardiology in all public hospitals. RESULTS: Twenty centers received the questionnaires; however, complete data was obtained from 18. Most interventional cardiology units in Israel are merely engaged in percutaneous coronary interventions (PCIs). PCIs are executed mostly via the femoral artery, using almost exclusively stents, of which 36% were drug eluting. Noted was an infrequent use of other therapeutic, diagnostic devices, or femoral arteriotomy closure devices. Only 22% of the patients receive glycoprotein IIb/IIIa blockers (GPB). Most centers used conventional unfractionated heparin dosing (70 u/kg) and did not routinely monitor activated clotting time. Abciximab, bivalirudin or enoxaparine were rarely used. All laboratories performed both elective and emergency-PCI, although 12 facilities were not supported by on-site surgical backup. CONCLUSION: Most cardiovascular intervention programs have restricted their activity to the coronary stenting, and are using a limited array of diagnostic and therapeutic devices, along with patient-tailored adjunctive pharmacotherapy, to sustain cost-effectiveness. Currently, ambulatory angiography and coronary interventions are not widely practiced in Israel.     

Ranking in Canadian gastroenterology residency match: What do residents and program directors want?

BACKGROUND:

Matching to a gastroenterology (GI) fellowship position in Canada is increasingly competitive.

OBJECTIVE:

To identify factors that determine how residents rank programs across the country, and how program directors rank their applicants.

METHODS:

Using input from several current GI trainees and former program directors, two separate surveys were developed. An online survey was sent one month after the match to every resident matched to an adult GI program in the 2007 match. A separate online survey was simultaneously sent to all program directors of 14 accredited GI programs in Canada. Two subsequent cohorts (2008 and 2009) of matched residents were surveyed during the annual GI fellow endoscopy course at McMaster University (Hamilton, Ontario).

RESULTS:

The overall response rate was 64 of 91 (70%) for residents and 11 of 15 (73%) for program directors (one program had codirectors). Using a five-point Likert scale for rating the importance of various factors influencing their decision, residents from three years ranked the following factor as most important: suitable location for spouse/partner/family (median score = 5). The overall least important factor was an opportunity for pediatric elective (median score = 2). Using the same scale, program directors ranked the following factors as most important (median score = 5) in ranking residents to their program: the ability to get along with others, outstanding reference letters, exceptional curriculum vitae and applying to only one specialty.

CONCLUSIONS:

Several factors important for GI applicants and program directors were identified, as well as a few less-important factors. Based on these results, GI training programs can more effectively market their programs to applicants in the future, and residents applying to GI programs can strengthen their applications in the ever competitive match process.     

Procedural skills training in internal medicine residencies. A survey of program directors

STUDY OBJECTIVE: To obtain the opinions of internal medicine residency program directors about which procedural skills residents master during training and the amount of training needed to attain and maintain competence in each procedure. DESIGN: A mailed survey to all program directors in the United States. RESPONDENTS: Program directors or their designees from 389 of 431 (90%) internal medicine residency programs. RESULTS: For several procedures, 40% more respondents said all residents should master the procedure than said all their residents do master the procedure. Some procedures commonly done in practice were perceived as mastered by all residents in fewer than half of the programs. There were few differences in procedures learned by size or type of program. A fellowship program did affect exposure to some procedures in the field covered by the program. Median recommendations of training needed to master each procedure were similar to those of practicing internists for most procedures. CONCLUSIONS: Current residency training does not assure competency in all of the procedures the general internist does in practice. Program directors should examine which skills are adequately taught, test competence, and ways to improve residents' skills. Practicing general internists should have access to supervised training in procedural skills.