The Objective of a Current Cardiology Training Program: Community-Based
RICHARD W. CAMPBELL, MD, FACC” Indianapolis, Indiana
The manpower and training report that has been referred to often in this Symposium indicates that there should be 5.6 cardiologists per 100,000 people. This ratio is approached in my state of Indiana in only the two large metropolitan areas of Indianapolis and Gary. It is clear that there is a maldistribution problem among physicians. Cardiologists finishing their fellowships tend to settle close to the centers where they took their cardiology fellowships. Of the 24 recent graduates of the cardiology training programs of Indiana University Medical Center who remained in Indiana, 22 established a practice in Indianapolis; only 2 settled in other parts of the state. In my judgment we must encourage the cardiologist to settle in the smaller communities where the patients are rather than continue to populate the larger centers. I suggest that training programs located in community hospitals might help to accomplish this.
Goals of Community-Based Training Program The goals of our training program are to train cardiac specialists and clinical cardiologists. They may be institutional or noninstitutional but they must be primary cardiologists providing patient care. They should be eligible for and be prepared to pass the American Board of Internal Medicine examination. They should be eligible for and prepared to pass the examination of the Subspecialty Board in Cardiovascular Disease. They should be knowledgeable about the natural history of disease and about how medical and surgical intervention can alter it both beneficially and harmfully, and they would know when this intervention is indicated. The only patients that they would need to refer would be those needing cardiac catheterization or cardiac surgery. They will know who these are. They will be expert in electrocardiography, including stress testing. They will be able to
Director of Internal Medicine Education, Methodist Hospital Graduate Medical Center, Indianapolis, Ind. Address for reprints: Richard W. Campbell, MD, Department of Internal Medicine Education, Methodist Hospital Graduate Medical Center, 1604 North Capital, Indianapolis, Ind. 46202. l
record and interpret echocardiograms, phonocardiograms, vectorcardiograms and other graphic tracings in those areas that are clinically applicable and useful but not necessarily in the esoteric research areas. Undoubtedly echocardiography is one of the greatest advances that has been made in cardiology in the past few years and, in deference to my dear friend, Harvey Feigenbaum, we have found it most useful clinically in mitral stenosis and pericardial effusions. But really, how useful is it for people in a community hospital to know which way the interventricular septum moves on the echogram in a patient with a left bundle branch block? The physicians we are training to go into the smaller communities not only should be able to interpret the noninvasive studies but also should be trained in how to perform these procedures. They should act as teachers for the general internists, the family practitioners, nurses and technicians. They should be capable of inserting pacemakers but, more importantly, they should know when pacemakers are indicated. They may be competent in cardiac catheterization but it is not absolutely necessary nor is it necessarily encouraged: Possibly we have trained too many cardiologists. We believe, however, ‘icatheterizing” that the training should exist in a center where cardiac catheterization and cardiac surgery are performed. Cardiac catheterization is a principal means of establishing complex diagnoses and providing precise physiologic data. Furthermore, cardiac catheterization and cardiac surgery should be performed in the training institution so as to acquaint the cardiology trainees with the indications for these procedures and to familiarize them with what the procedures can and cannot do. I am concerned that some of the generalists want everyone with chest pain or a heart murmur catheterized; I would hope that our cardiologists would be more discriminating. In the manpower report there is a table listing the average number of hours spent in the specific training areas in 2 year cardiology programs. This table is a composite of the programs that were evaluated. Approximately one third of the time was spent in pa-
October 31,1975
The American Journal of CARDIOLOGY
Volume 36
569
COMMUNITY-BASED TRAINING PROGRAM-CAMPBELL
tient care, and certainly this experience can be provided in a community hospital. Annually at our hospital we care for 500 patients with acute myocardial infarction. Twenty percent of the time was spent in invasive procedures, cardiac catheterizations and pacemaker insertions, and these too can be provided in a community hospital. Seven hundred thirty-seven cardiac catheterizations were performed and 200 pacemakers were inserted in our institution last year. Fifteen percent of the training time in the composite fellowship program described by the manpower report was spent on noninvasive procedures. I do not believe that this is enough time devoted to these procedures. This experience can be provided at community hospitals. In the last year more than 31,000 electrocardiograms, 190 vectorcardiograms, 835 phonocardiograms, more than 1,000 echocardiograms and 850 treadmill tests were performed in our institution. Community hospitals can have sufficient staff to support such a program; we have 11 members of our staff who would meet the definition of a cardiac specialist.
Evaluation of a Cardiac Fellow I would like also to discuss the evaluation of a cardiac fellow that is carried out in our hospital. We have a full-time director of medical education. An internal medicine education committee meets regularly on a monthly basis to review educational policies. Each resident and each fellow has a special group of three counselors. On a day by day basis the fellow is assigned to an individual faculty member. These faculty members develop rapport with the fellow as well as a sense of responsibility for his training and evaluation. As we have heard from Saul Farber, the American Board of Internal Medicine evaluates the candi-
570
October
31, 1975
The American
Journal of CARDIOLOGY
dates who take the ABIM certifying examination according to the performance in various subspecialty areas; we are cognizant of this reflection of perfor mance. Methodist Hospital, a community hospital, ranked 28th among 295 programs in the cardiology section of the ABIM certifying examination. We didn’t do as well in some of the other subspecialties and we wouldn’t feel justified in offering fellowships in those subspecialties.
Maintenance of Cllnical Competence How does one maintain the clinical competency of the practicing cardiologist? I believe that the best way to do this is to actively engage the cardiologist as a faculty member in the training programs. A teacher often learns the most. A training program requires teaching conferences on a regularly scheduled basis. The community physician participates actively in this learning exercise. Also to ensure competency there is a staff committee dealing with cardiovascular policies, designating and allocating privileges, determining who can perform catheterizations, pacemaker insertions and so forth. In our hospital we hold a weekly cardiac catheterization conference. Eight of our staff perform cardiac catheterizations. Each of the catheterizations performed during a week must be presented to the conference. In that way the individual cardiologist has to justify his indications for the procedure, display the quality of his work and expose the complications and the disposition of the patient to free and frank discussion. Probably the greatest justification for having a training program in a community hospital is that it ensures the quality of performance and competency of the practicing cardiologist.
Volume 36
RICHARD W. CAMPBELL, MD, FACC” Indianapolis, Indiana
The manpower and training report that has been referred to often in this Symposium indicates that there should be 5.6 cardiologists per 100,000 people. This ratio is approached in my state of Indiana in only the two large metropolitan areas of Indianapolis and Gary. It is clear that there is a maldistribution problem among physicians. Cardiologists finishing their fellowships tend to settle close to the centers where they took their cardiology fellowships. Of the 24 recent graduates of the cardiology training programs of Indiana University Medical Center who remained in Indiana, 22 established a practice in Indianapolis; only 2 settled in other parts of the state. In my judgment we must encourage the cardiologist to settle in the smaller communities where the patients are rather than continue to populate the larger centers. I suggest that training programs located in community hospitals might help to accomplish this.
Goals of Community-Based Training Program The goals of our training program are to train cardiac specialists and clinical cardiologists. They may be institutional or noninstitutional but they must be primary cardiologists providing patient care. They should be eligible for and be prepared to pass the American Board of Internal Medicine examination. They should be eligible for and prepared to pass the examination of the Subspecialty Board in Cardiovascular Disease. They should be knowledgeable about the natural history of disease and about how medical and surgical intervention can alter it both beneficially and harmfully, and they would know when this intervention is indicated. The only patients that they would need to refer would be those needing cardiac catheterization or cardiac surgery. They will know who these are. They will be expert in electrocardiography, including stress testing. They will be able to
Director of Internal Medicine Education, Methodist Hospital Graduate Medical Center, Indianapolis, Ind. Address for reprints: Richard W. Campbell, MD, Department of Internal Medicine Education, Methodist Hospital Graduate Medical Center, 1604 North Capital, Indianapolis, Ind. 46202. l
record and interpret echocardiograms, phonocardiograms, vectorcardiograms and other graphic tracings in those areas that are clinically applicable and useful but not necessarily in the esoteric research areas. Undoubtedly echocardiography is one of the greatest advances that has been made in cardiology in the past few years and, in deference to my dear friend, Harvey Feigenbaum, we have found it most useful clinically in mitral stenosis and pericardial effusions. But really, how useful is it for people in a community hospital to know which way the interventricular septum moves on the echogram in a patient with a left bundle branch block? The physicians we are training to go into the smaller communities not only should be able to interpret the noninvasive studies but also should be trained in how to perform these procedures. They should act as teachers for the general internists, the family practitioners, nurses and technicians. They should be capable of inserting pacemakers but, more importantly, they should know when pacemakers are indicated. They may be competent in cardiac catheterization but it is not absolutely necessary nor is it necessarily encouraged: Possibly we have trained too many cardiologists. We believe, however, ‘icatheterizing” that the training should exist in a center where cardiac catheterization and cardiac surgery are performed. Cardiac catheterization is a principal means of establishing complex diagnoses and providing precise physiologic data. Furthermore, cardiac catheterization and cardiac surgery should be performed in the training institution so as to acquaint the cardiology trainees with the indications for these procedures and to familiarize them with what the procedures can and cannot do. I am concerned that some of the generalists want everyone with chest pain or a heart murmur catheterized; I would hope that our cardiologists would be more discriminating. In the manpower report there is a table listing the average number of hours spent in the specific training areas in 2 year cardiology programs. This table is a composite of the programs that were evaluated. Approximately one third of the time was spent in pa-
October 31,1975
The American Journal of CARDIOLOGY
Volume 36
569
COMMUNITY-BASED TRAINING PROGRAM-CAMPBELL
tient care, and certainly this experience can be provided in a community hospital. Annually at our hospital we care for 500 patients with acute myocardial infarction. Twenty percent of the time was spent in invasive procedures, cardiac catheterizations and pacemaker insertions, and these too can be provided in a community hospital. Seven hundred thirty-seven cardiac catheterizations were performed and 200 pacemakers were inserted in our institution last year. Fifteen percent of the training time in the composite fellowship program described by the manpower report was spent on noninvasive procedures. I do not believe that this is enough time devoted to these procedures. This experience can be provided at community hospitals. In the last year more than 31,000 electrocardiograms, 190 vectorcardiograms, 835 phonocardiograms, more than 1,000 echocardiograms and 850 treadmill tests were performed in our institution. Community hospitals can have sufficient staff to support such a program; we have 11 members of our staff who would meet the definition of a cardiac specialist.
Evaluation of a Cardiac Fellow I would like also to discuss the evaluation of a cardiac fellow that is carried out in our hospital. We have a full-time director of medical education. An internal medicine education committee meets regularly on a monthly basis to review educational policies. Each resident and each fellow has a special group of three counselors. On a day by day basis the fellow is assigned to an individual faculty member. These faculty members develop rapport with the fellow as well as a sense of responsibility for his training and evaluation. As we have heard from Saul Farber, the American Board of Internal Medicine evaluates the candi-
570
October
31, 1975
The American
Journal of CARDIOLOGY
dates who take the ABIM certifying examination according to the performance in various subspecialty areas; we are cognizant of this reflection of perfor mance. Methodist Hospital, a community hospital, ranked 28th among 295 programs in the cardiology section of the ABIM certifying examination. We didn’t do as well in some of the other subspecialties and we wouldn’t feel justified in offering fellowships in those subspecialties.
Maintenance of Cllnical Competence How does one maintain the clinical competency of the practicing cardiologist? I believe that the best way to do this is to actively engage the cardiologist as a faculty member in the training programs. A teacher often learns the most. A training program requires teaching conferences on a regularly scheduled basis. The community physician participates actively in this learning exercise. Also to ensure competency there is a staff committee dealing with cardiovascular policies, designating and allocating privileges, determining who can perform catheterizations, pacemaker insertions and so forth. In our hospital we hold a weekly cardiac catheterization conference. Eight of our staff perform cardiac catheterizations. Each of the catheterizations performed during a week must be presented to the conference. In that way the individual cardiologist has to justify his indications for the procedure, display the quality of his work and expose the complications and the disposition of the patient to free and frank discussion. Probably the greatest justification for having a training program in a community hospital is that it ensures the quality of performance and competency of the practicing cardiologist.
Volume 36
