JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 8, NO. 2, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER INC.
ISSN 1936-8798/$36.00 http://dx.doi.org/10.1016/j.jcin.2014.12.219
EDITOR’S PAGE
Competency-Based Education Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions
F
or those of us who still think of educational
competent interventional cardiologist may have
levels as the number of years in school, semes-
become more difficult.
ter hours taken, or post-graduate degrees
In the next month or so, a new COCATS training
accumulated, we have to realize that there is a major
document for cardiology will be released and will be
movement in higher education toward “competency-
consistent with the competency-based education
based education.” The word “competency” seems to
mandated by the American Board of Medical Spe-
be used in many ways, and as it applies to physicians
cialists. Competencies will be set up in 6 domains:
and future physician training, perhaps it is worth-
1) medical knowledge; 2) patient care and procedural
while for us to reflect on what is meant by the de-
skills; 3) systems-based practice; 4) practice-based
velopers of educational systems. If someone asks me
learning and improvement; 5) professionalism; and
whether to see a specific doctor, and I respond, “Well,
6) interpersonal and communication skills. Within
he is competent,” I am not sure I have provided a
the 3-year training program, the maximum time point
ringing endorsement. Competence in this context
for achieving these competencies will be identified.
seems to be a qualitative measure that requires some
Various competencies have been well thought out
modification, such as “highly.” As I look at several
and vetted through many reviews. The difficult part
definitions of competence-based education, I read a
will be in judging whether the fellow has achieved
more dichotomous measure of the ability to know or
competence in these specific requirements. Formally,
do something without much definition of where the
we could have judged fellows rather subjectively as
bar is set for that performance. It would appear that
being “good” or “super,” or perhaps more quantita-
just south of competence is incompetence. Does
tively on a 10-point scale for overall performance, but
competence mean meeting minimal standards, or are
this would leave the judgment of whether the person
there gradations in competence? Is this important in
is competent in various areas unknown. Rating
cardiology?
trainees on a 10-point scale usually resulted in
The American Board of Medical Specialists, as
lumping people together at the upper end with all
some of you are aware, has instituted milestones to
fellows being, to paraphrase Garrison Keillor, “above
be achieved in our graduate medical education. As far
average” (1). The ACC has developed training tools for
as cardiology and interventional cardiology are con-
program directors and faculty to understand this new
cerned, we are all aware that the American Board of
world of competence-based education. Levels of
Internal Medicine provides an opportunity to sit for
competence have been developed for various mile-
an examination that will attempt to measure the
stones. Here, we begin to see how a trainee could be
competence of the candidates for initial or subse-
judged at various points in training on a 5-point scale:
quent recertification. When we began the interven-
level 1—critical deficiencies; level 2—early learner;
tional cardiology boards 15 years ago, we assumed
level 3—advanced/improving; level 4—ready for un-
that trainees would need a certain amount of time
supervised practice; and level 5—aspirational. If this
and a certain volume of experience to achieve a level
more nuanced measure of competence is applied to
of training that would earn them the designation of
the various milestones, you can see that a fellow early
cardiologist or interventional cardiologist. As our
in training entering the catheterization laboratory
field has evolved, new knowledge and new skills have
would be expected to have critical deficiencies,
been added at a rapid pace, so the definition of a
although this would not be a damning assessment of
King
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 8, NO. 2, 2015 FEBRUARY 2015:374–5
Editor’s Page
the fellow’s first day in the catheterization laboratory.
time and volume requirements toward achievement-
However, at what point in training will the fellow
defined competencies, I see a bit of schizophrenia in
achieve the designation of level 4 and be ready for
terms of how much time will be required to accom-
unsupervised practice, so that the trainee can
plish those goals. I do not think in the near term we are
“consistently and effectively perform and interpret
going to totally get away from time commitment and
all aspects of cardiac catheterization procedure;
volume on the basis of prior experience, but
constantly recognize appropriate indications and in-
competency-based education is a laudable goal. At the
dividual patient risk; and is able to manage compli-
present time, the process established for cardiology is
cations that occur during or as a result of the
being applied to cardiology subspecialties as well, but
procedure.” What if a fellow is judged to have this
this may require significant modification for inter-
level of competence after being exposed to 100
ventional cardiology given the potential for branching
catheterization procedures, whereas another fellow
directions in training toward structural heart disease,
has not achieved this level after 300 procedures? Will
peripheral vascular disease, and so forth.
the patient mix play an important role in this com-
For those who set standards in education and
petency area of patient care, and will the quality of
training, standardization is an obvious goal. Achieving
the supervision and mentoring also play a role? How
competence is a worthy goal, and quantification of
will the supervising faculty adjudicate what level of
the degree of competence is something we all expect.
competence a trainee has achieved throughout the
As the COCATS document for cardiology is rolled out,
training process for all the many milestones that have
we should give thought to how those core compe-
been defined? This sounds like a daunting task, but
tencies will need to be modified for interventional
the ACC has instituted a program including webinars
cardiology training and whether that training needs
to help training directors understand and deal with
to transform with additional milestones that will
these new requirements. It will be interesting to see
reflect the various competencies needed to address
how these changes will be implemented, and I am
the myriad of circumstances now within the realm of
certain that this will be an iterative process, in which
our discipline. There will be a lot of heavy lifting for
a great deal will be learned from the process itself.
training program directors, and they will be the ones
Whereas the COCATS document is to cover the 3-year cardiology program, training documents for
in the forefront of molding the educational process for our continuously evolving subspecialty.
interventional cardiology have not been developed. There is a process to evaluate electrophysiology
ADDRESS CORRESPONDENCE TO: Dr. Spencer B.
training with the potential of moving to a 2-year
King III, Saint Joseph’s Heart and Vascular Institute,
training requirement. As I think about competence-
5665 Peachtree Dunwoody Road NE, Atlanta, Georgia
based
30342. E-mail:
[email protected].
education,
which
is
moving
REFERENCE 1. BrainyQuote. Garrison Keillor quotes. Available at: http://www.brainyquote.com/quotes/quotes/g/garri sonke137097.html. Accessed December 30, 2014.
away
from
375