The Objective of a Current Cardiology Training Program: Institution-Based
H. J. C. SWAN, MD, PhD, FACC” Los Angeles, California
My task is to identify objectives of training programs and the outcomes obtained in our own program to date. Walter Abelmann has discussed the profiles established for individual physicians who personally identify themselves as cardiologists. More specifically, these include (1) the internist-cardiologist, (2) the clinical cardiologist, and (3) the cardiac specialist as useful separate descriptors of substantively different clinically oriented activities in an increasing order of technical complexity and specific knowledge content. Finally, (4) the academic cardiologist provides continued teaching and the investigative development of new knowledge at both the basic and clinically applied levels. The Cedars-Sinai
The training program at Cedars-Sinai was initially developed to provide background and training primarily for the cardiac specialist and the academic cardiologist. This program has been in existence for 9 years. We accept fellows, preferably at graduate level 4, although at times an unusually qualified person is accepted at graduate level 3. At present, we receive between 40 and 60 applications for admission to our 2 year program. We appoint six to seven fellows each year, of whom all but one or two will be at the first year level. Occasionally, fellows will have had a previous year of cardiology training at another institution; they are then designated second year fellows. Only two of our trainees failed to complete their planned program. About 30 percent of the appointees already have passed their boards in internal medicine prior to their fellowship; and another 40 to 50 percent pass their boards in internal medicine during their fellowship. More recently, the majority of fellows completPast President, American College of Cardiology; Professor of Medicine and Director of the Cardiovascular Training Program, The Cedars-Sinai Medical Center, Los Angeles, Calif. Address for reprints: H. J. C. Swan, MD, Department of Cardiology, University of California at Los Angeles, Cedars-Sinai Medical Center, 4833 Fountain Ave., Los Angeles, Calif. 90029. l
ing their training have made prompt application to the Subspecialty Board in Cardiovascular Disease. The first year of training is spent in six periods, of 2 months each, in (1) the noninvasive laboratory (including echocardiography); (2) the coronary care unit; (3) the heart station; (4) the cardiac catheterization laboratory; (5) the in-patient cardiology service; and (6) the cardiovascular surgical service. The objective is to provide an exposure to the sub-areas of expertise in cardiovascular medicine and to establish in the trainee’s mind the indications for and potential hazards of procedures together with the strengths and limitations of such approaches. The second year has been structured more to meet individual needs. Thus, one fellow may show evidence of competency in cardiac catheterization and he will be favored to obtain further experience in this discipline. Another may define an interest in, for example, echocardiography and spend a more extended period of time in the laboratory of noninvasive procedures. The members of the Department of Cardiology at Cedars-Sinai Medical Center have faculty rank in the Department of Medicine at the University of California at Los Angeles. Three members are full professors, one an associate professor and four assistant professors. I report to my Chairman of Medicine and all of my staff have additional responsibilities in general internal medicine. Results of Training What has been the outcome of this program? In the first 6 years a total of 34 physicians completed this program and have now been “settled” for 2 or more years. Only one of these physicians can be described as an internist-cardiologist. However, approximately a third are best described as consultant cardiologists, a fourth as cardiac specialists, and two fifths as academic cardiologists. Of the latter group, less than half are actively engaged in a major research program. This relates to the activities during
The American Journal ol CARDIOLOGY
their training. Those individuals with the inner personal drive and incentive to carry effectively to completion a research project appear to sustain that effort in their further careers. However, those who fail to participate, or participate in a superficial manner, conduct no research after completion of training. At present, 15 fellows are in clinical training at Cedars-Sinai Medical Center. Of these, three are graduates of our own residency program in internal medicine, four were graduated outside the U.S. and Canada, and eight additional physicians are graduates of U.S. programs. In addition to recruits from local residency programs, more than 50 percent of U.S. graduates have come from the Eastern seaboard or north central area of the country. Of the 34 persons who have completed our program, only three U.S. graduates have taken positions outside of California. Of 10 physicians graduated outside the U.S., 6 have returned to their own countries. Of the nonacademic cardiologists, two thirds currently reside in southern California. Of the academic cardiologists (40 percent), two remain in southern California and the remainder are widely dispersed. The majority of our current trainees and fellows have as their prime objective the acquisition of technical skills in the field of cardiology. They wish to qualify for the examination of subspecialty certification in cardiovascular diseases. The great majority wish to continue in a direct patient care activity throughout their careers. In other words, we are producing the clinical cardiologist and cardiac specialist.
October 31, 1975
Journal of CARDIOLOGY
A majority-about 60 percent-of our trainees have thus gone to the community to provide cardiovascular practice of a specialty type.
Future Goals I suspect that we will alter our goals in the future in regard to training in clinical cardiology. This will be done in cooperation with our Department of Internal Medicine. We wish to introduce into our program a commitment to provide appropriate rotations through cardiology, to allow trainees in internal medicine to fulfill community cardiovascular needs clearly defined in the report of Dr. Abelmann. Specifically, the common diseases in cardiovascular medicine are essential hypertension, congestive heart failure, ischemic heart disease and cardiac arrhythmias. We must develop a systematic program for residents in internal medicine to provide appropriate levels of knowledge and performance in the diagnosis and management of these illnesses. For community needs it is clear that graduates of programs in family practice and in internal medicine will have to provide care for the great majority of patients with cardiovascular problems. Finally, it would be within the broad objectives of this training program to alter in the future to meet the unmet needs for individual physicians in academic cardiology-that is, those who will acquire and assimilate knowledge (research), and then effectively distribute that knowledge as teachers of cardiovascular medicine and related disciplines.