As contemporary advancements in scientific knowledge and technology are incorporated into clinical practice, the need for medical education to evolve with similar frequency and agility is heightened. The healthcare workforce relies heavily on an influx of new trainees who must receive high-quality education if they are to contribute to their highly specialized fields. Currently, the Accreditation Council of Graduate Medical Education (ACGME) sets a framework of skills and knowledge that physicians must demonstrate in order to progress through their training. However, the pathway to meeting those competencies is not always clear.
The practice of cardiology lies at the intersection of multiple complex imaging modalities, including invasive coronary angiography (ICA), that are not typically taught in the traditional medical school curriculum. ICA, in particular, is the gold standard for the diagnosis of coronary artery disease, the most prevalent heart disease in the US.1 There is a surprising lack of research surrounding effective teaching and learning methodologies in the field of cardiology, especially with regard to ICA.2 Therefore, a survey study was designed to assess gaps in education and available resources regarding the interpretation of coronary angiography for medical students and physician trainee learners.
Methods
A survey comprising 20 questions was formulated and distributed via SurveyMonkey, an online survey platform. The full survey has been provided in the supplementary material. Solicitations to complete the survey were disseminated via the CardioNerds email newsletter to all CardioNerds ambassadors (fellows-in-training nominated to represent their fellowship program at CardioNerds by their program director at select fellowship programs) with instructions to forward the invitation to other learners in their programs, as well as through social media on X. As part of the questionnaire, respondents answered multiple-choice and open-ended inquiries, providing information on their demographics, training pathway and opinions regarding their education with respect to ICA interpretation. ICA interpretation was defined as being able to correctly identify the basic anatomy of the coronary tree, including major coronary arteries and branch arteries. The intended audience included all medical trainees, ranging from medical students through to subspecialty fellows, which was confirmed by reporting the names of their training centers. All surveys were submitted anonymously.
Results
Demographics
Data from 144 respondents predominantly in the US was acquired, with only six non-US respondents. Participants ranged from medical students to fellows. The largest response group was postgraduate year 4 (PGY-4) fellows (n=19; 13%) with 42% (n=59) of participants on a general cardiology fellowship. The remainder of participants were medical students (n=27; 19%), internal medicine residents (n=26; 18%), general surgery residents (n=16; 11%) and interventional cardiology fellows (n=5; 4%) with less than 3% of respondents from each of the following programs: electrophysiology (n=2), advanced heart failure (n=2), cardiovascular surgery fellow (n=1) and other (n=4). Men accounted for 50% (n=70) of the participants, women accounted for 45% (n=63) of participants and agender, non-binary or prefer not to say accounted for 5% (n=8). Participant race was predominately white (n=71; 50%) followed by Asian (n=29; 20%) and Black or African–American (n=13; 9%). Thirty-six per cent (n=52) of participants anticipate specializing in interventional cardiology, followed by general cardiology (n=31; 22%), electrophysiology (n=20; 14%), advanced heart failure (n=8; 13%), cardiovascular surgery (n=9; 6%), general surgery (n=3; 2%), and other (n=10; 7%).
Coronary Angiography Exposure
Most participants (n=108; 77%) recorded over 4 weeks of in-person experience in the cardiac catheterization laboratory (CCL) per year. Thirty-five per cent (n=49) of participants spent 4–12 weeks/year and 31% (n=44) spent 13–24 weeks/year in the CCL. Only 12% (n=17) noted a complete absence of exposure to the CCL (Figure 1). Most participants (n=115; 81%) were moderately or less comfortable with interpreting coronary angiography (n=44 [31%] moderately, n=50 [35%] mildly, and n=21 [15%] not comfortable). Only 4% (n=6) of respondents noted they were highly comfortable and able to interpret angiograms independently. Similarly, among general cardiology fellows alone, most (n=52; 86%) characterized their comfort with interpreting coronary angiographic imaging as moderate or less (Figure 2).
Coronary Angiography Education
The most used resource for coronary angiogram interpretation was on-the-job training, selected by 73% (n=102) of participants, followed by online resources (n=84; 60%) and textbooks (n=54; 39%). On-the-job training was also noted to be the most helpful (n=77; 55%) and most prevalent resource (n=96; 67%) in learning how to interpret coronary angiography, followed by online resources (29% [n=40] and 52% [n=75], respectively) and textbooks (13% [n=18] and 44% [n=63], respectively) (Figure 3). Half of participants (n=72; 50%) only used time while at work to learn how to interpret ICA with 26% (n=37) studying both at work and independently at home at least weekly, 13% (n=19) reporting less than weekly independent study, and 8% (n=11) less than monthly. The most commonly selected limitation for learning how to interpret ICA was the lack of resources outside of work (n=63; 45%) followed by other work/personal obligations (n=62; 44%). The most popular challenge when learning ICA was insufficient resources (n=65; 46%), followed by insufficient teaching at the learner level despite time spent in the CCL (n=53; 37%).
Improved Coronary Angiography Knowledge Impact
The majority of participants strongly agreed (n=80; 56%) or agreed (n=35; 24%) that developing a better understanding of ICA would contribute to their understanding of cardiology and/or improve their future practice/knowledge. Additionally, over half of all participants agreed that the knowledge gained through improved training might have changed or might still have the potential to change their choice of specialty or career path (strongly agree 29% [n=41], agree 31% [n=44]).
Discussion
In summary, the current research supporting medical education in the field of cardiology is scant, particularly with respect to commonly used imaging-based tools like ICA. ICA involves the acquisition of X-ray-based fluoroscopy coupled with the injection of contrast media into the epicardial coronary arteries to diagnose and help manage patients with coronary artery disease. Traditionally, to our knowledge, teaching ICA is not part of standardized medical education curriculums. Unfortunately, learning how to interpret ICA is complicated, with several major challenges including: anatomic variation, contrast degradation or X-ray exposure limits that impair visibility of coronary contours, vessel overlap, or obscurement by implanted equipment/devices, such as sternal wires, mechanical valves, implantable pacemakers, or defibrillators.
This survey aimed to identify and understand gaps in learning how to interpret ICA. The results of this survey study suggest the following: most students/trainees use on-the-job training to learn ICA, most respondents were not comfortable interpreting coronary angiograms independently, and a better understanding of ICA might affect personal choice of specialty or even future clinical practice. These results imply a need for not only dedicated educational time, but also the creation of updated learning resources.
Specifically, the overwhelming majority (81%) of participants in the survey (consisting of 42% general cardiology fellows) characterized their comfort levels when interpreting coronary angiographic imaging as moderate or less. However, 66% of learners spent more than 4 weeks per year in the CCL. Among the choices given, the two major barriers to learning were insufficient resources and insufficient time outside of work. Taken together, this data would seem to suggest that solely relying on in-person training at work is not sufficient for gaining the requisite knowledge.
Current ACGME guidelines state that general cardiology fellows should demonstrate competency in performing coronary angiography and spend a minimum of 3 months in the cardiac catheterization laboratory by the completion of their fellowship program.3 However, core competencies regarding the interpretation of basic coronary anatomy from fluoroscopic imaging is not overtly specified, nor is this directly testable knowledge on the cardiovascular board examination.
Interestingly, of those respondents who were third year general cardiology fellows, 83% reported they were still moderately or less comfortable with ICA interpretation during their third year of fellowship. This finding suggests a definite knowledge gap that could be filled by supplemental resources prior to graduation, either from in-person training or asynchronous learning resources such as web-based didactics.
In procedural fields of medicine, we are increasingly turning towards sophisticated simulation models to assist with training and predict performance in the field.4 One 2014 study performed in Sweden was designed to assess whether a learning course of lectures along with coronary angiography simulator training would improve performance in the CCL. Unfortunately, the participants demonstrated no clear benefit (as measured by complications and fluoroscopy time) compared with controls.5 Given the paucity of studies in this realm, it remains to be seen to what extent such resources can provide benefit to clinical skills.
Particularly in post-graduate trainees, as dedicated study time becomes sparser and required knowledge becomes more specialized at each successive level, delivering high-quality education becomes more challenging. An advantage of this survey was the ability to gain the medical student/trainee perspective, a valuable insight to have when discussing opportunities for learning improvement. We may be able to use the extra time offered to junior learners interested in cardiology and introduce them to ICA before entering the field. Access to free or low-cost online resources, such as a set of imaging modules, would help facilitate this.
Conclusion
The results of this survey strengthen our belief that an online set of imaging modules available outside of the workplace that facilitates the attainment of proficiency in ICA would promote better understanding of cardiology, inform future practice, and assist trainees when choosing a career path. Limitations of this study include the subjective nature of self-assessment and the small number of respondents.
Importantly, the field of cardiology might ultimately benefit from further studies examining the impact of such resources on clinical performance.
Clinical Perspective
- Most students/trainees use on-the-job training to learn invasive coronary angiography.
- Most respondents were not comfortable interpreting coronary angiograms independently.
- A better understanding of ICA might affect personal choice of specialty or even future clinical practice.