Competency-Based Medical Education for Fellowship Training During the COVID-19 Pandemic

The American College of Cardiology has developed comprehensive recommendations for fellowship training in cardiovascular medicine and many of its subspecialties through competence and training statements. Key features of these documents include the principles of competency-based medical education (CBME), including delineation of specific competencies, and estimates of the minimum number of procedures or duration of training required by typical trainees to ensure adequate exposure to the clinical breadth within the content area. As the COVID-19 (coronavirus disease 2019) pandemic continues to have an impact on health care systems, potential disruption of the educational components of cardiology training may pose challenges for some fellows to meet number-based requirements. As such, it is important to emphasize the role of CBME to all stakeholders.

The Core Cardiovascular Training Statement (COCATS 4) and Advanced Training Statements clearly delineate the principles of CBME in their introductions (1, 2, 3, 4). Although these training statements often suggest a minimum number of procedures necessary to achieve levels of training, performance, and/or interpretation of a given number of procedures is neither synonymous with satisfactory completion nor sufficient to define adequate training. The numbers are intended as general guidance based on the educational needs and progress of typical trainees and should be considered approximate. Time-based requirements should also be considered estimates to facilitate scheduling, reflecting the periods required by the typical trainee to gain requisite knowledge, skills, and experience in each subdiscipline. Finally, COCATS 4 states that some requirements in time and case numbers may be satisfied concurrently, depending on the particular design, resources, and evaluation methods of the program.

For both general cardiology and advanced training, the program director is ultimately responsible for reviewing the progress of individual trainees to ensure achievement of training milestones, confirming experience and competence upon completion of fellowship, and identifying areas in which additional focused training may be required. The program director is empowered to render a decision on competencies achieved at the end of formal training, regardless of whether an individual fellow met or exceeded individual time- or number-based standards. The program director must also ensure that robust and effective evaluation and assessment processes are in place. Additionally, the eligibility requirements for certification boards must be considered, along with guidance that these boards may provide relevant to the pandemic.

We believe that a focus on CBME provides the flexibility needed during this time of unprecedented disruption to our medical institutions and training programs. In a time of extraordinary pressure on the health care system and its professionals, it is important to keep the public interest in mind by maintaining a rigorous educational infrastructure while also providing flexibility in training so the workforce can serve the public good when and where needed. We endorse the recommendations from the Accreditation Council for Graduate Medical Education in this regard, which include the following:

“Traditional time-based or volume-based measures may not be fully achievable during this period. The current environment is not ‘normal,’ and each program should use the principles of CBME and the guidance below to make informed decisions about advancement, graduation, and board eligibility. Educational experiences may be modified or disrupted through alternative forms of education, such as virtual learning, deployment to another clinical rotation or activity (e.g., ICU, ED, wards, telemedicine), or by missing a traditionally required rotation” (5).

It is understood, however, that there will be concerns about fulfilling requirements for board eligibility and/or employer or hospital credentialing. Although a comprehensive review of board requirements is beyond the scope of this statement, program directors and fellows should be aware of several points. First, for many cardiology boards (cardiology, adult congenital, heart failure), minimum procedural numbers are not defined. Second, for the procedure-intensive specialties (interventional cardiology and electrophysiology), there is some element of “flexibility” in the requirements either by virtue of timing (e.g., some procedures during general fellowship may count) or generality of the requirement (i.e., the subtypes of procedures are not defined). Third, some of the non-American Board of Medical Specialties imaging boards have or are considering additional flexibility in requirements, such as permitting additional training after the usual 3-year program. In brief, we urge both board certification bodies and credentialing authorities to consider adopting strategies that permit some flexibility while still maintaining the protection of the public interest. These strategies may include reliance on program director attestation of competency and/or allowing additional training or mentoring post-fellowship.

Thus, we urge all program directors to use the principles of CBME, and the flexibility inherent in the training recommendations, to guide decisions on the educational needs and clinical competence of fellows. We remind fellows that the principles of CBME imply that competence is not achieved simply by meeting a time- or number-based metric, but by demonstrating proficiency in the knowledge, skills, and behaviors related to our field. Given the ongoing impact of COVID-19 on traditional training, achieving competence may require increased self-directed learning, remote case review, or incorporation of alternative training methods such as simulation (6). It is important to note, however, that irrespective of the degree to which “flexibility” is considered in training, the program director has both the authority and obligation to sign off on competency only when competency has been achieved using the CBME educational framework. Encompassed in this framework are appropriate assessment methods.

Finally, we would like to thank the fellows for their dedication to patient care during the COVID-19 pandemic and the program directors and faculty for providing innovative methods to promote education to trainees. We recognize the sacrifices you have all made to serve your communities, and appreciate and applaud your efforts.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.