The American College of Cardiology Core Cardiovascular Training Statement (COCATS) defines echocardiography core competencies to achieve in fellowship training, as well as the minimum recommended number of echocardiograms to perform (150) and interpret (300) for independent practice in echocardiography. Our study demonstrated that cardiology fellows lacked exposure to a number of cardiac pathologies related to core competencies in their echocardiography training despite meeting the minimum recommended numbers for level 2 training by COCATS. The relative infrequency of certain pathologies among the core competencies defined in COCATS suggests that fellowship programs should consider monitoring pathology case counts for each fellow, beyond overall number of studies interpreted, to ensure adequate exposure during the course of fellowship training.
Gaps in exposure to cardiac pathologies during echocardiography training may lead to lack of proficiency in interpreting pathology during clinical practice. To assess fellow proficiency in echocardiography, Nair et al. investigated third year cardiology fellows who had performed a mean of 261 echocardiograms and interpreted a mean of 353 echocardiograms during cardiology training (both exceeding level 2 COCATS standards) and found multiple areas in which 50% or more of fellows failed to achieve a passing score on a dedicated echocardiography interpretation observed structured clinical examination (OSCE). Clinical scenarios where fellows failed to demonstrate proficiency in interpretation included ascending aortic aneurysm complicated with aortic regurgitation (44% pass rate) and interpretation of bioprosthetic valve dysfunction (11% pass rate) . Only a weak correlation was found between the number of echocardiograms interpreted and interpretations scores on the OSCE (r = 0.33) , suggesting that total procedural numbers may be inadequate to reflect proficiency. Our study expands on this prior research by demonstrating that multiple cardiac pathologies described in COCATS are encountered much less frequently during echocardiography training; this may help to explain fellows’ lack of proficiency in interpreting pathologies such as prosthetic valve dysfunction despite exceeding minimum recommend numbers.
We found that the lower numeric requirement of echocardiograms to perform (at least 150) compared to echocardiograms to interpret (at least 300) resulted in an increase in absolute and relative deficiencies to cardiac pathologies among fellows when comparing echocardiograms performed to echocardiograms interpreted. This discrepancy may disproportionately affect cardiology fellows’ ability to identify and evaluate pathology when performing echocardiography. A prior survey of graduating cardiology fellows regarding self-perceived echocardiography competency found that a greater percentage of fellows perceived themselves to be “highly” or “extremely highly” proficient at interpreting echocardiography (78%) as compared to performing echocardiography (54%) . Our study may explain these findings in part by demonstrating that a reduced exposure to cardiac pathologies among echocardiograms performed, due to lower numeric training requirements, may contribute to this self-perception of inadequate competency in performing echocardiography.
The implications of our study extend beyond fellow competency in echocardiography. Training statements as part of COCATS 4 cover a wide variety of skills and study interpretation, including competencies in cardiac MRI, nuclear cardiology, and cardiovascular computed tomographic imaging, among others. In each case, expected competencies and milestones are outlined for proficiency, along with recommended minimum procedural numbers and time in training for each area. Chow et al. found that in the area of nuclear cardiology, fellows demonstrated variables rates of achieving competency in interpretation based on agreement with attending final interpretation, and on average cardiology fellows required higher numbers of procedures to achieve competency beyond the minimum number of studies recommended in COCATS . Fellowship programs should consider adopting a strategy of monitoring pathology case counts, encountered through a combination of study interpretation, case conferences, and didactics, to ensure adequate exposure to each area of core competency.
Cardiology fellowship programs may use a variety of approaches to broaden fellows’ exposure to echocardiography pathologies when deficiencies in pathology case counts are identified. Strategies may include lecture series, case conferences to review key cardiac pathologies, and/or case logs to document the variety of pathologies encountered. Attending physicians may consider archiving cases with uncommon or rare yet significant pathologies for fellows to review to ensure adequate exposure to key pathologies. Direct observations, as well as structured in-training assessments such as OSCEs, may also enable fellowship programs to identify deficiencies and enable targeted feedback. A study by Nielsen et al. described use of an OSCE for assessing technical proficiency in performing transthoracic echocardiography in patients with normal cardiac function as well as with aortic stenosis and with mitral regurgitation, which assessment tool fellowship programs may find useful as a model for assessing competency in performing echocardiography . Fellowship clinical competency committees may consider different methods for providing appropriate assessment and feedback during echocardiography training .
Simulated echocardiography, where available, may offer another modality for supplementing core competencies in echocardiography education. Use of echocardiography simulation has been demonstrated to be an effective tool for teaching and assessment of competency in transthoracic [9, 10] and transesophageal [11,12,13,14] echocardiography. Current software is now capable of simulating not only normal cardiac function but also valve dysfunction, abnormal wall motion, cardiac tamponade, and aortic dissection, among others, allowing fellows to have standardized modules for assessment and practice, particularly in areas of potential deficiency . Our data suggest that use of such modules could be useful given the rarity of certain cardiac pathologies included in COCATS. Additionally, for programs without access to simulation mannequins, the use of online echocardiography simulation software exists which may be used to supplement learning [16, 17], with limited studies suggesting that use of online simulation resources may also be beneficial for echocardiography training [18, 19].
A number of important limitations should be considered in reviewing our results. As a retrospective study, our data were extracted from echocardiography reports. Exposure to certain echocardiography pathologies may have been under-counted if these pathologies were not specified in the final echocardiography report. Our study was a review of fellows within a single training program; specific areas of deficiency in echocardiography exposure are likely to vary at other institutions. Our institution has a dedicated adult congenital heart disease program, along with cardiac surgery and structural heart programs. Cardiology fellowship programs at smaller centers without these programs may find that fellows encounter less instances of certain cardiac pathologies, such as prosthetic valve dysfunction or congenital heart disease, for example.
All fellows at our institution exceeded to some degree the minimum recommended numbers in training, and therefore many may have encountered additional cardiac pathologies when accounting for their total numbers performed and interpreted. Additionally, fellows may gain exposure to key cardiac pathologies in other rotations even when they are not involved as the primary interpreter or performer of the echocardiogram, such as exposure to pericardial tamponade and constriction as the fellow in the cardiac catheterization laboratory, or to aortic dissection as the fellow rounding in the cardiovascular intensive care unit. Systems developed by fellowship programs to track pathology exposure across training will help to elucidate areas of deficiency that may not be readily apparent from individual fellow case counts of studies performed and interpreted. Further research is also needed to determine whether gaps in exposure to cardiac pathologies during fellowship training lead to meaningful impacts in study interpretation and patient outcomes during clinical practice.