Education curriculum assessment for teaching electrocardiography: Rationale and design for the prospective, international, randomized controlled EDUCATE trial.

BACKGROUND: Electrocardiogram (ECG) interpretation training is a fundamental component of medical education across disciplines. However, the skill of interpreting ECGs is not universal among medical graduates, and numerous barriers and challenges exist in medical training and clinical practice. An evidence-based and widely accessible learning solution is needed. DESIGN: The EDUcation Curriculum Assessment for Teaching Electrocardiography (EDUCATE) Trial is a prospective, international, investigator-initiated, open-label, randomized controlled trial designed to determine the efficacy of self-directed and active-learning approaches of a web-based educational platform for improving ECG interpretation proficiency. Target enrollment is 1000 medical professionals from a variety of medical disciplines and training levels. Participants will complete a pre-intervention baseline survey and an ECG interpretation proficiency test. After completion, participants will be randomized into one of four groups in a 1:1:1:1 fashion: (i) an online, question-based learning resource, (ii) an online, lecture-based learning resource, (iii) an online, hybrid question- and lecture-based learning resource, or (iv) a control group with no ECG learning resources. The primary endpoint will be the change in overall ECG interpretation performance according to pre- and post-intervention tests, and it will be measured within and compared between medical professional groups. Secondary endpoints will include changes in ECG interpretation time, self-reported confidence, and interpretation accuracy for specific ECG findings. CONCLUSIONS: The EDUCATE Trial is a pioneering initiative aiming to establish a practical, widely available, evidence-based solution to enhance ECG interpretation proficiency among medical professionals. Through its innovative study design, it tackles the currently unaddressed challenges of ECG interpretation education in the modern era. The trial seeks to pinpoint performance gaps across medical professions, compare the effectiveness of different web-based ECG content delivery methods, and create initial evidence for competency-based standards. If successful, the EDUCATE Trial will represent a significant stride towards data-driven solutions for improving ECG interpretation skills in the medical community.

Validity of a cardiology fellow performance assessment: reliability and associations with standardized examinations and awards.

BACKGROUND: Most work on the validity of clinical assessments for measuring learner performance in graduate medical education has occurred at the residency level. Minimal research exists on the validity of clinical assessments for measuring learner performance in advanced subspecialties. We sought to determine validity characteristics of cardiology fellows' assessment scores during subspecialty training, which represents the largest subspecialty of internal medicine. Validity evidence included item content, internal consistency reliability, and associations between faculty-of-fellow clinical assessments and other pertinent variables. METHODS: This was a retrospective validation study exploring the domains of content, internal structure, and relations to other variables validity evidence for scores on faculty-of-fellow clinical assessments that include the 10-item Mayo Cardiology Fellows Assessment (MCFA-10). Participants included 7 cardiology fellowship classes. The MCFA-10 item content included questions previously validated in the assessment of internal medicine residents. Internal structure evidence was assessed through Cronbach's α. The outcome for relations to other variables evidence was overall mean of faculty-of-fellow assessment score (scale 1-5). Independent variables included common measures of fellow performance. FINDINGS: Participants included 65 cardiology fellows. The overall mean ± standard deviation faculty-of-fellow assessment score was 4.07 ± 0.18. Content evidence for the MCFA-10 scores was based on published literature and core competencies. Cronbach's α was 0.98, suggesting high internal consistency reliability and offering evidence for internal structure validity. In multivariable analysis to provide relations to other variables evidence, mean assessment scores were independently associated with in-training examination scores (beta = 0.088 per 10-point increase; p = 0.05) and receiving a departmental or institutional award (beta = 0.152; p = 0.001). Assessment scores were not associated with educational conference attendance, compliance with completion of required evaluations, faculty appointment upon completion of training, or performance on the board certification exam. R2 for the multivariable model was 0.25. CONCLUSIONS: These findings provide sound validity evidence establishing item content, internal consistency reliability, and associations with other variables for faculty-of-fellow clinical assessment scores that include MCFA-10 items during cardiology fellowship. Relations to other variables evidence included associations of assessment scores with performance on the in-training examination and receipt of competitive awards. These data support the utility of the MCFA-10 as a measure of performance during cardiology training and could serve as the foundation for future research on the assessment of subspecialty learners.

Burnout and Well-Being Among Cardiology Fellowship Program Directors.

OBJECTIVES: The third annual Cardiovascular Diseases (CV) Fellowship Program Directors (PDs) Survey sought to understand burnout and well-being among CV fellowship PDs. BACKGROUND: Physician burnout is a common phenomenon. Data on burnout among cardiologists, specifically CV PDs, remain limited. METHODS: The survey contained 8 questions examining satisfaction, stress, and burnout among CV fellowship PDs. Burnout was defined based on the self-reported presence of ≥1 symptom of burnout, constant feelings of burnout, or complete burnout. RESULTS: Survey response rate was 57%. Most respondents were men (78%) and 54% represented university-based programs. Eighty percent reported satisfaction with their current job as PD, and 96% identified interactions with fellows as a driver of their satisfaction. Forty-five percent reported feeling a great deal of stress from their job. Stress was higher among women PDs, early-career PDs, and PDs of larger and university-based programs. Twenty-one percent reported some symptoms of burnout, and only 36% reported enjoyment without stress or burnout. Rates of enjoyment without stress or burnout were higher among men and late-career PDs, PDs of smaller programs, and PDs of community-based programs. Seventeen percent of PDs reported a high likelihood of resigning in the next year, of which the most common reason was the tasks of PDs were becoming overwhelming. CONCLUSIONS: Most CV fellowship PDs are satisfied with their position, but stress and burnout remain common. Women PDs, early-career PDs, and PDs of larger, university-based programs demonstrate more adverse markers of well-being. Opportunities exist to support CV fellowship PDs in their critical role.

Characteristics of internal medicine residents who successfully match into cardiology fellowships.

BACKGROUND: The unique traits of residents who matriculate into subspecialty fellowships are poorly understood. We sought to identify characteristics of internal medicine (IM) residents who match into cardiovascular (CV) fellowships. METHODS: We conducted a retrospective cohort study of 8 classes of IM residents who matriculated into residency from 2007 to 2014. The primary outcome was successful match to a CV fellowship within 1 year of completing IM residency. Independent variables included residents' licensing exam scores, research publications, medical school reputation, Alpha Omega Alpha (AOA) membership, declaration of intent to pursue CV in the residency application personal statement, clinical evaluation scores, mini-clinical evaluation exercise scores, in-training examination (ITE) performance, and exposure to CV during residency. RESULTS: Of the 339 included residents (59% male; mean age 27) from 120 medical schools, 73 (22%) matched to CV fellowship. At the time of residency application, 104 (31%) had ≥1 publication, 38 (11%) declared intention to pursue CV in their residency application personal statement, and 104 (31%) were members of AOA. Prior to fellowship application, 111 (33%) completed a CV elective rotation. At the completion of residency training, 108 (32%) had ≥3 publications. In an adjusted logistic regression analysis, declaration of intention to pursue CV (OR 6.4, 99% CI 1.7-23.4; p < 0.001), completion of a CV elective (OR 7.3, 99% CI 2.8-19.0; p < 0.001), score on the CV portion of the PGY-2 ITE (OR 1.05, 99% CI 1.02-1.08; p < 0.001), and publication of ≥3 manuscripts (OR 4.7, 99% CI 1.1-20.5; p = 0.007) were positively associated with matching to a CV fellowship. Overall PGY-2 ITE score was negatively associated (OR 0.93, 99% CI 0.90-0.97; p < 0.001) with matching to a CV fellowship. CONCLUSIONS: Residents' matriculation into CV fellowships was associated with declaration of CV career intent, completion of a CV elective rotation, CV medical knowledge, and research publications during residency. These findings may be useful when advising residents about pursuing careers in CV. They may also help residents understand factors associated with a successful match to a CV fellowship. The negative association between matching into CV fellowship and overall ITE score may indicate excessive subspecialty focus during IM residency.

Preoperative Dobutamine Stress Echocardiography and Clinical Factors for Assessment of Cardiac Risk after Noncardiac Surgery.

BACKGROUND: The role of dobutamine stress echocardiography (DSE) in the risk stratification of patients undergoing noncardiac surgery in the current era is unclear. The aim of this study was to evaluate the yield of DSE and the additive role of DSE to clinical criteria for preoperative risk stratification of patients undergoing noncardiac surgery. METHODS: The study included 4,494 patients undergoing DSE ≤90 days before noncardiac surgery. The primary outcome was a composite of postoperative myocardial infarction, cardiac arrest, and all-cause mortality ≤30 days after noncardiac surgery. RESULTS: The overall 30-day postoperative cardiac event rate was 2.3%. The mortality rate was 0.9% overall and 0.7% and 1.3% after normal and abnormal results on DSE, respectively. Among clinical variables, the modified Revised Cardiac Risk Index score demonstrated the strongest association with postoperative risk (P < .001). Patients with Revised Cardiac Risk Index scores of ≥3 had an event rate of 7.5%. The event rates for patients with wall motion score index ≥1.7 at baseline, left ventricular ejection fractions <40% at peak stress, or ischemic thresholds <70% of age-predicted maximal heart rate were 7.1%, 8.6%, and 7.9%, respectively. After adjusting for clinical variables, the overall result of DSE (P < .001), baseline and peak-stress wall motion score index (P < .001 and P = .014, respectively), peak-stress left ventricular ejection fraction (P < .001), and the number of ischemic segments (P = .027) were all associated with postoperative cardiac events. Incremental multivariate analysis demonstrated that an overall abnormal result on DSE, added to clinical variables, was associated with an increased risk for postoperative cardiac events (odds ratio, 2.07; 95% CI, 1.35-3.17; P < .001). CONCLUSIONS: Baseline and peak-stress findings on preoperative DSE add to the prognostic utility of clinical variables for stratifying cardiac risk after noncardiac surgery.

COCATS 4: Securing the Future of Cardiovascular Medicine.

The latest iteration of the Core Cardiology Training Statement (COCATS 4) [Corrected] provides a potentially transformative advancement in cardiovascular fellowship training intended, ultimately, to improve patient care. This review addressed 3 primary themes of COCATS 4 from the perspective of fellows-in-training: 1) the evolution of training requirements culminating in a competency-based curriculum; 2) the development of novel learning paradigms; and 3) the establishment of task forces in emerging areas of multimodality imaging and critical care cardiology. This document also examined several important challenges presented by COCATS 4. The proposed changes in COCATS 4 should not only enhance the training experience but also improve trainee satisfaction. Because it embraces continual transformation of training requirements to meet evolving clinical needs and public expectations, COCATS 4 will enrich the cardiovascular fellowship training experience for patients, programs, and fellows-in-training.

Assessment of left ventricular outflow gradient: hypertrophic cardiomyopathy versus aortic valvular stenosis.

OBJECTIVES: This study examined the relationship between peak-to-peak (common invasive measurement), peak instantaneous (common Doppler measurement), and mean pressure gradients in patients with hypertrophic cardiomyopathy (HCM) and aortic stenosis (AS). BACKGROUND: In patients with AS, the peak-to-peak gradient and peak instantaneous gradient are discrepant, and the mean gradient best represents obstruction severity. The pathophysiology of outflow obstruction differs in HCM, with the maximum gradient occurring in late systole, thus the optimal method for quantifying gradient severity in HCM remains undefined. METHODS: Fifty patients with HCM and 50 patients with AS underwent gradient characterization at cardiac catheterization (age 55 ± 15 years vs. 72 ± 9 years; 48% vs. 42% male, respectively). All HCM patients were studied with high-fidelity, micromanometer-tip catheters and transseptal measurement of left ventricular inflow and central aortic pressures. In AS, simultaneous left ventricular and central aortic pressures were recorded. RESULTS: The peak instantaneous gradient was linearly correlated with peak-to-peak gradient in HCM (R(2) = 0.98, p < 0.0001), with the relationship close to the line of identity. In AS, more scatter and further deviation from the line of identity occurred when comparing the peak instantaneous gradient to the peak-to-peak gradient (R(2) = 0.70, p < 0.0001). Both peak-to-peak and peak instantaneous gradients were consistently higher than the mean gradient in HCM, with wide 95% confidence limits of agreement (26.7 ± 46.5 mm Hg and 16.4 ± 47.2 mm Hg, respectively). CONCLUSIONS: In HCM, peak instantaneous and peak-to-peak gradient demonstrate excellent correlation. Consequently, both peak instantaneous and peak-to-peak gradients can be used to classify obstruction severity in HCM. By contrast, the mean gradient should direct clinical management in AS.