COCATS 4 Introduction

Transcription

1 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 65, NO. 17, 2015 ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN /$36.00 PUBLISHED BY ELSEVIER INC. COCATS 4 Itroductio Joatha L. Halperi, MD, FACC Eric S. Williams, MD, MACC Valeti Fuster, MD, PHD, MACC 1. EVOLUTION OF TRAINING RECOMMENDATIONS FOR SPECIALISTS IN ADULT CARDIOVASCULAR MEDICINE Recommedatios for traiig i adult cardiovascular medicie were first published i the Joural i 1995 as a cosesus statemet emaatig from the Core Cardiology Traiig Symposium (COCATS) held at Heart House i Bethesda, Marylad, the previous year (1). The term COCATS has sice bee used whe referrig to the America College of Cardiology (ACC) curriculum recommedatios for fellowship programs ad has come to desigate the Core Cardiology Traiig Statemet (rather tha the symposium). The 1995 recommedatios were cotaied i 10 Task Force reports coverig overall traiig i cliical cardiology ad specialized areas of cardiovascular medicie. As advaces i cardiovascular sciece ad techology evolved, traiig recommedatios were revised extesively i 2002 ad published as COCATS 2 (2). I that iteratio, the 10 origial Task Force reports were updated ad additioal reports were developed that addressed traiig recommedatios i the areas of vascular medicie, catheter-based peripheral vascular itervetios, ad cardiovascular magetic resoace imagig. Subsequet evolutio ecessitated further revisios, ad traiig recommedatios for cardiac electrophysiology ad cardiac computed tomography were first published i 2006 as a update to COCATS 2 (3) ad the as a full revisio (COCATS 3) i 2008 (4). As i previous COCATS documets, the terms fellow ad traiee are used iterchageably, as are cardiovascular medicie ad cardiology. 2.OVERSIGHTOFPOSTGRADUATE EDUCATION FOR SPECIALISTS IN CARDIOVASCULAR MEDICINE Regulatory oversight of traiig i iteral medicie ad its subspecialties is provided by the Accreditatio The America College of Cardiology requests that this documet be cited as follows: Halperi JL, Williams ES, Fuster V. COCATS 4 itroductio. J Am Coll Cardiol 2015;65: Coucil for Graduate Medical Educatio (ACGME) ad its Iteral Medicie Residecy Review Committee. The ACGME establishes both commo ad subspecialty-specific program requiremets regardig traiig duratio, istitutioal ifrastructure, faculty leadership ad cliicia educators, ad traiig eviromet ad safety, as well as the miimum requiremets for program cotet. Whereas the ACGME accredits traiig programs, the America Board of Iteral Medicie (ABIM) certifies idividuals as specialists i cardiovascular disease. Successful completio of traiig i a program with ACGME accreditatio is a requiremet to sit for the ABIM Cardiovascular Disease certifyig examiatio. Although the ACGME, ABIM, ad ACC represet idepedet orgaizatios, their aligmet o traiig stadards is importat, ad COCATS has bee a importat cotributor to the developmet of the traiig requiremets for cardiovascular disease. COCATS provides additioal curricular cotet detail beyod the ACGME miimum requiremets for geeral cardiovascular disease to defie progressive levels of skill ad competecy i desigated areas. Over the past several years, there has bee a progressive move toward competecy-based traiig, the key characteristic of which is evaluatio focused o specific learer outcomes. The cetral requiremets of such traiig are to delieate the specific compoets of competecy withi the subspecialty, defie the tools ecessary to assess traiig, ad establish milestoes that should be met as fellows progress toward idepedece. This evolutio is maifested i COCATS 4, icludig the overarchig 6-domai structure (Table 1) promulgated by the ACGME/America Board of Medical Specialties (ABMS)adedorsedbytheABIM(5). These competecies should be iterpreted, developed, ad evaluated i the cotext of subspecialty traiig, recogizig that more basic competecies i these domais will or should have bee acquired durig residecy traiig i iteral medicie, a prerequisite for cardiovascular fellowship. Furthermore, maiteace of core competecies over the course of oe s professioalcareerisasimportatas iitial competecy acquisitio.

2 JACC VOL. 65, NO. 17, 2015 MAY 5, 2015: Halperi et al. COCATS 4 Itroductio 1725 TABLE 1 ACGME Core Competecies Patiet Care that is compassioate, appropriate, ad effective for treatig health problems ad promotig health. Medical Kowledge about established ad evolvig biomedical, cliical, ad cogate (e.g., epidemiological ad social-behavioral) scieces ad the applicatio of this kowledge to patiet care. Practice-Based Learig ad Improvemet that ivolve ivestigatio ad evaluatio of a fellow s patiet care, self-appraisal, ad assimilatio of scietific evidece, ad improvemets i patiet care. Iterpersoal ad Commuicatio Skills that result i effective iformatio exchage ad teamig with patiets, their families, ad other health professioals. Professioalism as maifested by a commitmet to carryig out professioal resposibilities, adherece to ethical priciples, ad sesitivity to a diverse patiet populatio. Systems-Based Practice as maifested by actios that demostrate a awareess of ad resposiveess to the larger cotext ad system of health care ad the ability to effectively call o system resources to provide care that is of optimal value. These miimum geeral competecies were edorsed by the ACGME i February 1999 ( ad all Residecy Review Committees ad Istitutioal Review Committees were to iclude this miimum laguage i their respective Program ad Istitutioal Requiremets by Jue The defiitios are available at cbi.lm.ih.gov/pmc/articles/pmc /. ACGME ¼ Accreditatio Coucil for Graduate Medical Educatio. Each COCATS Task Force report that follows covers a specific field of competecy i cardiovascular disease, icludes curricular cotet (milestoes) withi each domai, ad lists potetial evaluatio tools. It is importat to emphasize several poits regardig the competecy tables that accompay each Task Force report. First, each curricular milestoe eed ot be idepedetly evaluated or documeted by a formal outcome measure; rather, represetative compoets may be assessed, or i some cases, assessed i aggregate. Secod, the curricular milestoes uderpi the more global ACGME/ABIM reportig milestoes (6); the ACC will also provide tools to facilitate mappig of the relevat curricular competecies that support achievemet of the more global ACGME/ABIM reportig milestoes. This is iteded to help traiig program directors respod to this reportig requiremet. Third, the 12-, 24-, ad 36-moth desigatios that appear i each competecy table are iteded as a roadmap for a typical fellow, helpig evaluators determie whether a idividual fellow is progressig o-track toward idepedet competecy. Traiig programs vary widely i their sequecig of educatioal experieces, ad fellows vary i the pace at which they achievecompetecy.thetimeestimatesaresimplyexamples ad may, therefore, ot apply to all programs or traiees. Variability is expected ad acceptable, as log as programs provide mechaisms to assess the developmet of key competecies over time. A supplemet to this documet gathers all of the tables i a compedium. The aggregated competecies described i COCATS 4 form the basis for the overarchig Etrustable Professioal Activities (EPAs) of our professio, amely, those activities that patiets ad the public expect all competet cliical cardiologists to be able to perform (Table 2). TABLE 2 Etrustable Professioal Activities for Subspecialists i Cardiovascular Disease Cardiovascular Cosultatio evaluate, diagose, ad develop treatmet plas for patiets with kow, with suspected, or at risk of developig cardiovascular disease. Acute Cardiac Care maage patiets with acute cardiac coditios. Chroic Cardiovascular Disease Maagemet maage patiets with chroic cardiovascular diseases. Cardiovascular Testig appropriately utilize cardiovascular testig. Disease Prevetio ad Risk Factor Cotrol implemet disease prevetio ad risk factor cotrol measures, addressig comorbidities. Team-Based Care work effectively to promote patiet-cetered iterdiscipliary team-based care. Lifelog Learig egage i lifelog learig. Some huma resource professioals draw a distictio betwee the terms competece ad competecy, usig competece to describe the actios ecessary to perform a fuctio optimally (cocered with effect ad output rather tha effort ad iput), ad competecy to describe the behaviors that lie behid optimum performace, such as critical thikig ad aalytical skills (describig what idividuals brig to the professio). Because performace requires a combiatio of behavior, attitude,adactio,the2termsareusediterchageably i the Task Force reports. 3. REVISION OF TRAINING COMPONENTS SINCE EARLIER ITERATIONS OF COCATS This iteratio of COCATS cotais a umber of structural chages i the cardiovascular curriculum sice the recommedatios issued i There is a substatially stroger focus o ambulatory, cosultative, ad logitudial care, reflectig a commitmet to patiet-cetric educatio i cliical cardiology. The itet is for traiig of the cardiologist as a cosultat with a logitudial commitmet to the care of the patiet to be pervasive throughout the 3-year geeral cardiology fellowship. The curriculum also icludes a requiremet that cotiuity cliics be itegrated with service rotatios i specialized fields such as heart failure, cogeital heart disease, geriatric cardiology, ad arrhythmias to ecompass traiig i this cotext. Two Task Force reports address areas of traiig ot covered i previous editios of COCATS: critical care cardiology ad multimodality oivasive cardiovascular imagig, although the latter was addressed as a separate publicatio i 2009 (7). A third report expads cosiderably o the pursuit of research ad scholarly activity durig fellowship traiig. This revisio emphasizes the importace of active participatio i research ad scholarly activities ad outlies a variety of approaches ad formats to meet this importat academic requiremet for cardiology traiees i the cotext of a commitmet to lifelog learig.

3 1726 Halperi et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Itroductio MAY 5, 2015: This revisio of COCATS icorporates the traiig recommedatios for the 4 basic oivasive imagig modalities echocardiography (Task Force 5), uclear cardiology (Task Force 6), cardiac computed tomography (Task Force 7), ad cardiovascular magetic resoace (Task Force 8) which are itroduced i a ew sectio o multimodality imagig (Task Force 4). Each was writte by a idividual writig group ad represets a revisio of a previously published documet, except for multimodality imagig, which icludes the chairs of the Task Forces for each compoet imagig modality ad experts i multimodality imagig. I the previous traiig paradigm, fellows ofte rotated through these laboratories as idividual silos of imagig techologies, with idividual cofereces ad separate didactic teachig offerigs attached to each modality. The 2008 Traiig Statemet o Multimodality Noivasive Cardiovascular Imagig idicated that ovel methods of traiig (e.g., allowig cocurret traiig ad cosolidatig curricula amog modalities) could allow fellows to develop higher-level expertise i more tha 1 modality i a 3-year fellowship (7). It is icreasigly importat to utilize multimodality imagig priciples i cofereces ad didactic sessios ad to critically discuss the beefits ad limitatios of various imagig techiques for a give cliical idicatio. As described i the echocardiography (Task Force 5) report, competece i both trasesophageal echocardiography ad cotrast echocardiography is ecessary to achieve Level II traiig (defied i Sectio 5); basic competece i stress echocardiography ca be achieved i Level II traiig. Additioal traiig beyod Level II is recommeded for full competece ad idepedece i advaced echocardiography. The eed for core traiig i procedural techiques, such as electrocardiography, ambulatory moitorig, ad covetioal exercise stress testig, is clearly defied, with the expectatio that traiees will develop icreasig sophisticatio i the applicatio of these techiques over the course of the 36-moth fellowship. Traiig i itervetioal cardiology as described i the Task Force 10 report is limited to formal traiig programs i the Uited States that satisfy the basic stadards developed by the ACGME ad are accredited by the ACGME. This Level III traiig must be achieved durig a fourth year of dedicated fellowship experiece. The Task Force 11 report idicates more specific procedural time ad case volume to gai expertise i cardiac implatable electroic device maagemet. Traiig i heart failure ad trasplatatio as outlied i the Task Force 12 report has bee revised relative to the 1995 ad 2002 reports. Level III traiig i heart failure ackowledges the requiremets of the Uited Network for Orga Sharig for heart trasplat physicias. Level III heart failure traiig will require at least 1 additioal year of traiig i advaced heart failure ad trasplatatio. 4. MIGRATION TO A COMPETENCY-BASED CURRICULUM COCATS 4 utilizes the 6 geeral competecy domais promulgated by the ACGME/ABMS (Table 1) todefie the core competecies i cliical cardiology, ad structures the curriculum for traiig to achieve them. The ACC has also adopted this format for its competecy ad traiig statemets, career milestoes, lifelog learig, ad educatioal programs ad has developed tools to assist physicias i assessig, ehacig, ad documetig competecies. Each Task Force report icludes a table delieatig the competecy domais ad associated curricular milestoes for traiig. The milestoes are categorized ito Level I, II, ad III traiig (defied i the followig text) ad idicate the stage of fellowship traiig (12, 24, or 36 moths, ad additioal time poits) by which the typical traiee should achieve the desigated level of competece. The tables also describe potetial evaluatio tools for assessig competece i each domai. Level I competecies may be achieved at earlier or later time poits. Although these tables delieate key competecy compoets, they are ot comprehesive, ad the full spectrum of competecy compoets required of Level I traied cardiologists is embodied i the Task Force reports that together delieate the traiig requiremets ad scope of curriculum. It is vital to the excellece of a traiig program that faculty help traiees develop cliical skills ad supervise, guide, ad critique performace ad iterpretatio of procedures. Although the Task Force reports provide, i some cases, miimum umbers of procedures that should be completed with acceptable outcomes to achieve levels of traiig, performace ad iterpretatio of a give umber of procedures is either syoymous with satisfactory completio or sufficiet to defie adequate traiig. The umbers of procedures performed ad/or iterpreted have bee developed to be cosistet with volume recommedatios foud i the ACC/ America Heart Associatio practice guidelies, ACC/ America Heart Associatio /America College of Physicias cliical competece statemets, expert cosesus statemets, ad other relevat cosesus documets, whe available; however, the specified volumes of tests or procedures performed ad/or iterpreted successfully to achieve competece are iteded as geeral guidace based o the educatioal eeds ad progress of typical traiees. Whe duratio of exposure or volume of

4 JACC VOL. 65, NO. 17, 2015 MAY 5, 2015: Halperi et al. COCATS 4 Itroductio 1727 procedures or cases has bee suggested, specified umbers should be cosidered approximate. The objectives are to esure exposure to a sufficiet breadth of cliical material ad pathology ad to provide faculty sufficiet opportuity to evaluate competecy i a give area. Similarly, approximate time frames are guides to facilitate schedulig, reflectig the periods required by the typical traiee to gai requisite kowledge, skills, ad experiece i each subdisciplie. Give the complexity ad time costraits of traiig programs, may of the requiremets i time ad case umbers i various procedures may be satisfied cocurretly. Examples iclude traiig i stress testig durig rotatios i echocardiography or uclear cardiology, ad experiece i cardiovascular magetic resoace or cardiac computed tomography iterpretatio durig other imagig rotatios. Level III This level of traiig requires additioal experiece beyod the geeral cardiology fellowship to acquire specialized kowledge ad competecies i performig, iterpretig, ad traiig others to perform specific procedures or for the traiee to reder advaced, specialized care at a high level of skill. Level III traiig caot geerally be obtaied durig the stadard 3-year geeral cardiology fellowship ad requires additioal exposure i a program that meets requiremets delieated i Advaced Traiig Statemets (formerly i Cliical Competece Statemets) ad developed for each specialized field of edeavor. Advaced (Level III) traied faculty should be available to participate i traiig Level I fellows i cardiac catheterizatio, itervetioal cardiology, ad cardiac electrophysiology, but are ot required for Level I traiig i other fields. 5. STRUCTURE AND LEVELS OF TRAINING The ABIM subspecialty board o cardiovascular disease requires 3 years of cardiology fellowship traiig. Additioal traiig beyod the stadard 3-year geeral cardiology fellowship is required to sit for certificatio examiatios i cliical cardiac electrophysiology, itervetioal cardiology, advaced heart failure ad trasplat cardiology, ad adult cogeital heart disease. As outlied i this documet, additioal years of traiig are also recommeded for traiees who desire advaced expertise i specialized areas, those who wat dedicated time for basic ad/or cliical research traiig, or both. I this revisio of COCATS, recommedatios for such advaced traiig experieces are proposed relative to the disciplie of cardiovascular medicie beig addressed. Throughout the Task Force reports, traiig is defied i terms of the followig levels: Level I The basic traiig required of all traiees to be competet cosultat cardiologists. This ca be accomplished durig a stadard 3-year traiig program i geeral cardiology. Level II This refers to the additioal traiig i 1 or more areas that eables some cardiologists to perform or iterpret specific diagostic tests ad procedures or reder more specialized care for specific patiets ad coditios. This level of traiig is recogized oly for those areas i which a atioally accepted istrumet or bechmark, such as a qualifyig examiatio, is available to measure specific kowledge, skills, or competece. Level II traiig may be achieved by some traiees i selected areas durig the stadard 3-year geeral cardiology fellowship, depedig o the traiee s career goals ad use of elective periods. The emphasis of COCATS is o Level I traiig delieatig competecies that all cardiology fellows must acquire durig the stadard fellowship that follows residecy traiig i iteral medicie. Level II traiig is defied for fields i which specific competecies ca be udertake durig about 6 moths of the 3-year traiig period (depedig upo the career focus of traiees) ad measured by a stadardized qualifyig istrumet such as a subspecialty examiatio. Level II traiig is ot available or described for fields lackig this criterio. Level III traiig is described oly i broad terms to provide cotext for traiees ad clarify that these advaced competecies are ot covered durig the geeral cardiology fellowship ad require a additioal period of traiig ad desigatio by a idepedet certificatio board, ofte coupled with a certifyig examiatio. The advaced traiig requiremets required to achieve Level III competecy will be addressed i subsequet, separately published cliical competece ad advaced traiig statemets. The Steerig Committee ad Task Forces recogize that implemetatio of these chages i traiig requiremets will occur icremetally over time. A summary of the various cliical rotatios is depicted coceptually i Figure 1. It is importat to emphasize that the itet of this diagram is to illustrate relatioships amog ad potetial overlaps across the various cliical ad educatioal experieces durig fellowship traiig rather tha the specific sequece or duratio of rotatios. Traiees vary with respect to the legth of time spet i each area of study based upo prior experiece, aptitude, career goals, ad iterests. Traiig i cardiovascular medicie ivolves the acquisitio of specialized skills ad capabilities i specific techologies as well as experieces i logitudial care ad scholarly activity that are pervasive across virtually the etire fellowship period.

5 1728 Halperi et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Itroductio MAY 5, 2015: FIGURE 1 The COCATS Curriculum for Level I Traiig i Cardiovascular Medicie This schematic summarizes the compoets of traiig durig the stadard 3-year cardiovascular fellowship. The various cliical rotatios are depicted i a coceptual format to illustrate relatioships ad potetial overlap across the various educatioal experieces rather tha the sequece or duratio of rotatios. Basic experieces i the acute hospital settig typically occur maily durig the first 24 moths, although i some cases, some experieces may be deferred to the third year. Exposure to oivasive diagostic testig modalities typically occurs at various poits throughout the fellowship as traiees develop the ability to itegrate the iformatio geerated by these modalities ito patiet care with icreasig sophisticatio. The outer rig of the diagram deotes logitudial experieces that pervade the etire fellowship traiig period. These iclude cosultative, ambulatory, ad logitudial patiet care ad itegratio of disease prevetio strategies ito patiet maagemet. Proportioate time frames idicated for each experiece represet those required by the typical fellow to acquire the required competecies but should be cosidered approximate. Depedig o available resources ad particular characteristics of some traiig programs ad the backgroud, skills, ad career goals of idividual traiees, it may be possible to combie certai compoets of traiig or to develop certai competecies cocurretly with others. Elective time may be devoted to additioal traiig i 1 or more areas selected o the basis of the idividual traiee s eeds ad career goals. This additioal exposure will eable some traiees to gai Level II competece to perform or iterpret certai procedures or reder more specialized care for specific patiets ad coditios. Time allocated to research ad scholarly activity may be scheduled cotiuously or at specific poits i the 36-moth fellowship depedig o the traiee s prior experiece, rate of progress, ad professioal objectives. ACHD ¼ adult cogeital heart disease; CCT ¼ cardiovascular computed tomography; CMR ¼ cardiovascular magetic resoace; CV ¼ cardiovascular; ECG ¼ electrocardiography. For the typical fellow, approximately half of a year durig the stadard 3-year fellowship could be allocated to pursuits aliged with the idividual s choice for subsequet advaced traiig. The idividual Task Force reports that iclude sectios o Level III traiig provide iformatio about acillary fields upo which fellows may choose to focus durig geeral cardiology traiig to better prepare them for advaced traiig i their area of iterest. The rapid evolutio of cardiovascular sciece ad cardiovascular medicie requires that all traiig programs have a experieced faculty, adequate facilities, ad a rich assortmet of didactic offerigs for fellows. Specific compoets are addressed i each Task Force report. Case-based cofereces are vital to trai fellows ad develop their skills i evidece-based decisio makig. Self-learig is emphasized, ad Iteret-based, olie educatioal programs, may of which 1 are iteractive, play a icreasigly importat role i learig durig fellowship ad beyod. Such didactic activities are outlied throughout the Task Force reports. I most cliical rotatios, emphasis should be placed o evidece-based practice guidelie recommedatios, stadards for recordig cliical data, ad appropriate use criteria for diagostic ad therapeutic procedures.

6 JACC VOL. 65, NO. 17, 2015 MAY 5, 2015: Halperi et al. COCATS 4 Itroductio 1729 The COCATS Steerig Committee, Task Force chairs ad members, ad ACC recogize the eed to assist traiees, faculty, ad program directors with the trasitio from the historical curriculum that was based o exposure time ad case volume to the curret competecy-based model. Also recogized is the related eed for faculty developmet tools to facilitate the assessmet of competecy amog fellows i traiig. The developers of COCATS are additioally aware of other challeges facig fellowship programs durig this trasitioal period related to ACGME/ABIM milestoe reportig requiremets, ad the writig groups allow for flexibility i implemetatio as log as the emphasis o competecy-based learig is preserved. 6. EVALUATION OF COMPETENCY AND REPORTING OF EDUCATIONAL MILESTONES A key characteristic of competecy- ad curricular milestoe-based traiig is itegratio with outcomesbased evaluatios. Evaluatio of competece is a itegral, cotiuous, ad critical part of the educatioal process for the cardiology fellow across the spectrum of traiig. Evaluatio tools iclude a variety of modalities, such as direct observatio by istructors, i-traiig examiatios, procedure logbooks, coferece ad case presetatios, multisource evaluatios, traiee portfolios, simulatio, ad self-reflectio. Case maagemet, judgmet, ad iterpretive ad techical skills must be evaluated regularly i every traiee ad discussed with the traiee at least twice aually. Quality of care ad follow-up; reliability; judgmet, decisios, or actios that result i complicatios; iteractio with other physicias, patiets, ad laboratory support staff; iitiative; ad the ability to make appropriate idepedet decisios should be cosidered. The ACGME distiguishes levels of advacemet i each of the geeral competecies usig milestoes that describe a developmetal progressio from early learer status through advacig or improvig competecy, readiess for usupervised practice, ad at the piacle, aspiratioal achievemet by learers. The program must develop a evaluatio system that accurately determies each fellow s progressio alog this developmetal cotiuum. Mechaisms should be icorporated so that fellows who perform suboptimally or who exhibit critical deficiecies ca be couseled ad provided with opportuities for corrective actio. Likewise, fellows who are progressig appropriately should be challeged to excel. With the curricular competecy milestoes, the ACC provides a schema for evaluatig the traiee s progressive competecy developmet over the course of the traiig program. This curricular milestoe framework facilitates specific feedback to traiees as they progress through traiig. As much as possible, methods for evaluatio ad documetatio of competece have bee stadardized across the various Task Force reports. A optimum traiig eviromet icludes bidirectioal evaluatios, i which faculty evaluate ad provide positive or egative feedback to traiees ad traiees evaluate faculty. The program director should review these evaluatios with the traiee ad faculty idividually ad collectively at group meetigs with both fellows ad faculty to address the curriculum ad traiig eviromet. Fellows ad faculty should be formally evaluated after each rotatio; timely evaluatios better eable traiees to process ad icorporate feedback ito their learig objectives. By usig a competecy- ad curricular milestoe-based framework, the ACC has idetified specific observable behaviors that, ideally, are easier to evaluate. I additio to easig evaluatio, this format should also aid i providig more specific feedback to traiees as they progress through multiple levels of traiig. Evaluatio may be accomplished usig a variety of modalities o a daily basis. It should iclude the aforemetioed tools, but may also iclude other iovative evaluatio methods as available. Overall cliical progress ad deficiecies should also be assessed for each traiee at least twice aually by the traiig program s Cliical Competecy Committee ad reported with recommedatios to the cardiology fellowship program director. Evaluatios are ultimately the resposibility of the fellowship program director ad should be performed at least twice aually for each fellow usig a variety of evaluatio tools. 7. COMPOSITION OF THE TASK FORCES AND INTEGRATION OF TRAINING RECOMMENDATIONS As kowledge i cardiovascular medicie cotiues to expad, traiig must keep pace. This report represets a cosesus ad was created usig the overall format of the previous COCATS documets. Idividual task forces were empaeled to address each compoet of traiig i cardiology ad structured similarly to iclude the followig members: represetatives of the ACC ad key cardiovascular subspecialty orgaizatios for a give field of study, a cardiovascular traiig program director who is ot a subspecialist i the subject of the particular report, a traiig program director i the particular field, a early-career cardiologist practicig i the field who has completed fellowship traiig withi 5 to 8 years, experieced specialists practicig i both academic ad commuity-based practice settigs, ad physicias experieced i developig ad applyig

7 1730 Halperi et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Itroductio MAY 5, 2015: traiig stadards accordig to the core competecies structure promulgated by the ACGME/ABMS. The writig groups reviewed the 2008 COCATS 3 Task Force reports ad made revisios, additios, ad deletios based o published data ad expert opiio. Major chages i curricular cotet most ofte related to evolutio of subspecialty areas i cardiology ad widespread acceptace of emergig techologies i cliical practice. Collectively, the Task Force reports reflect a broad effort to establish cosistet traiig criteria across all aspects of cardiology. 8. DOCUMENT REVIEW AND ENDORSEMENT COCATS 4 was reviewed by 55 exteral peer reviewers, culmiatig i over 900 commets that were addressed by authors. The etire documet was peer reviewed by the ACC Competecy Maagemet Committee, the Cardiology Traiig ad Workforce Committee, ad a member of the ACC Board of Trustees ad the ACC Board of Goverors. A member of the ACC Competecy Maagemet Committee served as lead reviewer to esure a fair ad balaced peer review resolutio process. Idividual Task Force reports were reviewed by the followig ACC coucils: Task Force 2 report: Prevetio of Cardiovascular Disease Sectio Leadership Coucil; Task Force 3 ad 11 reports: Electrophysiology Sectio Leadership Coucil; Task Force 4 to 8 reports: Imagig Sectio Leadership Coucil; Task Force 9 report: Peripheral Vascular Disease Sectio Leadership Coucil; Task Force 10 report: Itervetioal Sectio Leadership Coucil; Task Force 12 report: Heart Failure ad Trasplat Sectio Leadership Coucil; ad Task Force 15 report: Academic Cardiology Sectio Leadership Coucil. Represetatives from several orgaizatios also reviewed the documet: Itroductio ad Task Force 1 ad 9 reports: the ABIM; Task Force 5 report: the America Society of Echocardiography; Task Force 6 ad 7 reports: the America Society of Nuclear Cardiology; Task Force 7 report: the Society of Cardiovascular Computed Tomography ad the Society of Atherosclerosis Imagig ad Prevetio; Task Force 7, 9, ad 10 reports: the Society for Cardiovascular Agiography ad Itervetios; Task Force 8 report: the Society for Cardiovascular Magetic Resoace; Task Force 9 report: the Society for Vascular Medicie; Task Force 11 report: the Heart Rhythm Society; ad Task Force 12 report: the Heart Failure Society of America. The America Heart Associatio reviewed the etire documet. All reviewers ad their affiliatios i the review process ad employmet iformatio ca be foud i the appedix cotaiig peer reviewer disclosure iformatio i each report. Followig peer review, the revised documet was posted for public commet from December 20, 2014, to Jauary 6, 2015, resultig i 34 additioal commets from a array of reviewers from both the commuity-based ad academic practice settigs, cardiovascular traiig program directors, sub-subspecialty traiig program directors, early-career professioals (i practice <8 years), fellows i traiig, ad govermet employees. The authors addressed these commets to fialize the documet. All idividual COCATS reports were approved by the respective Task Forces, the COCATS Steerig Committee, ad the ACC Competecy Maagemet Committee ad were subsequetly ratified by the ACC Board of Trustees. Edorsemet by participatig societies is reflected i each Task Force report. This documet is cosidered curret util the ACC Competecy Maagemet Committee revises or withdraws it. 9. AUTHOR AFFILIATIONS The Steerig Committee is grateful for the time ad effort devoted to this COCATS revisio by the Task Force members ad reviewers who provided valuable iput. Staff of the America College of Cardiology provided superb support to the COCATS 4 effort, ad their cotributios are recogized with appreciatio. The ACC determied that relatioships with idustry or other etities were ot relevat to the creatio of this geeral cardiology traiig statemet; however, employmet ad affiliatio iformatio for authors ad peer reviewers are provided i Appedixes 1 ad 2, respectively, alog with disclosure reportig categories. Comprehesive disclosure iformatio for all authors, icludig relatioships with idustry ad other etities, is available as a olie supplemet to this documet. ACC PRESIDENT AND STAFF Patrick T. O Gara,MD,MACC,Presidet Shalom Jacobovitz, Chief Executive Officer William J. Oetge, MD, MBA, FACC; Executive Vice Presidet, Sciece, Educatio, ad Quality Jaice Sibley, MS, MA, Vice Presidet, Educatio Roby Syder, BS, Team Lead, Educatio Desig Daw R. Phoubadith, MSW, Director, Competecy Maagemet Taja Kharlamova, Associate, Physicia Cliical Pathways Kimberly Kooi, MHA, Associate, Educatio Desig Projects Grace Roa, Team Lead, Policy Publicatio Amelia Scholtz, PhD, Publicatios Maager, Cliical Policy ad Pathways

8 JACC VOL. 65, NO. 17, 2015 MAY 5, 2015: Halperi et al. COCATS 4 Itroductio 1731 REFERENCES 1. America College of Cardiology. COCATS guidelies for traiig i adult cardiovascular medicie: Core Cardiology Traiig Symposium. Jue 27-28, J Am Coll Cardiol 1995;25: Beller GA, Boow RO, Fuster V. ACC revised recommedatios for traiig i adult cardiovascular medicie: core cardiology traiig II (COCATS 2) revisio of the 1995 COCATS traiig statemet. J Am Coll Cardiol 2002;39: Beller GA, Boow RO, Fuster V. ACCF 2006 update for traiig i adult cardiovascular medicie (focused update of the 2002 COCATS 2 Traiig Statemet): a report of the America College of Cardiology Foudatio/America Heart Associatio/America College of Physicias Task Force o Cliical Competece ad Traiig. Itroductio. J Am Coll Cardiol 2006;47: Beller GA, Boow RO, Fuster V. ACCF 2008 recommedatios for traiig i adult cardiovascular medicie core cardiology traiig (COCATS 3) revisio of the 2002 COCATS traiig statemet. J Am Coll Cardiol 2008;51: Nasca TJ, Philibert I, Brigham T, Fly TC. The ext GME accreditatio system: ratioale ad beefits. N Egl J Med 2012;366: Gitli S, Flaherty J, Arrighi J, et al. The Iteral Medicie Subspecialty Milestoes Project: a joit iitiative of the Accreditatio Coucil for Graduate Medical Educatio ad the America Board of Iteral Medicie i collaboratio with the Alliace for Academic Iteral Medicie. Available at: acgme.org/acgmeweb/portals/0/pdfs/milestoes/ IteralMedicieSubspecialtyMilestoes.pdf. Accessed February 25, Thomas JD, Zoghbi WA, Beller GA, et al. ACCF 2008 traiig statemet o multimodality oivasive cardiovascular imagig: a report of the America College of Cardiology Foudatio/America Heart Associatio/ America College of Physicias Task Force o Cliical Competece ad Traiig. J Am Coll Cardiol 2009;53: KEY WORDS ACC Traiig Statemet, COCATS, fellowship traiig, cliical competece APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) COCATS 4 INTRODUCTION Committee Member Employmet Cosultat Speakers Bureau Owership/ Partership/ Pricipal Persoal Research Istitutioal/ Orgaizatioal or Other Fiacial Beefit Expert Witess Joatha L. Halperi Eric S. Williams Valeti Fuster Icah School of Medicie at Mout Siai Professor of Medicie Idiaa Uiversity School of Medicie Professor (Cardiology) ad Associate Dea; Idiaa Uiversity Health Cardiology Service Lie Leader Icah School of Medicie at Mout Siai, Zea ad Michael A. Wieer Cardiovascular Istitute Director For the purpose of developig a geeral cardiology traiig statemet, the ACC determied that o relatioships with idustry or other etities were relevat. This table reflects the authors employmet ad reportig categories. To esure complete trasparecy, authors comprehesive healthcare-related disclosure iformatio icludig relatioships with idustry ot pertiet to this documet is available i a olie data supplemet. Please refer to relatioships-with-idustry-policy for defiitios of disclosure categories, relevace, or additioal iformatio about the ACC Disclosure Policy for Writig Committees. ACC ¼ America College of Cardiology.

9 1732 Halperi et al. JACC VOL. 65, NO. 17, 2015 COCATS 4 Itroductio MAY 5, 2015: APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (RELEVANT) COCATS 4 INTRODUCTION Name Employmet Represetatio Cosultat Speakers Bureau Owership/ Partership/ Persoal Pricipal Research Istitutioal/ Orgaizatioal or Other Fiacial Beefit Expert Witess Richard Kovacs Idiaa Uiversity, Kraert Istitute of Cardiology Q.E. ad Sally Russell Professor of Cardiology Official Reviewer, ACC Board of Trustees Dhaujaya Lakkireddy Kasas Uiversity Cardiovascular Research Istitute Official Reviewer, ACC Board of Goverors Howard Weitz Thomas Jefferso Uiversity Hospital Director, Divisio of Cardiology; Sidey Kimmel Medical College at Thomas Jefferso Uiversity Professor of Medicie Official Reviewer, Competecy Maagemet Committee Lead Reviewer Furma McDoald America Board of Iteral Medicie Vice Presidet Graduate Medical Educatio, Departmet of Academic Affairs; Professor, Medicie ABIM Alla Klei Clevelad Cliic Professor, Medicie; Director, Pericardial Ceter ASE Deis Calo OhioHealth Heart ad Vascular Physicias Director, Cardiac Imagig, Riverside Methodist Hospital ASNC Kousik Krisha Rush Uiversity Medical Ceter Associate Professor, Medicie ad Pediatrics; Director, Arrhythmia Device Cliic Heart Rhythm Society Richard Patte Lahey Hospital Ad Medical Ceter, Divisio of Cardiovascular Medicie HFSA Joh Hodgso Metrohealth Medical Ceter SCAI Michael Ragosta Uiversity of Virgiia Health System, Cardiovascular Divisio SCAI Aditya M. Sharma Uiversity of Virgiia Health System, Cardiovascular Divisio Assistat Professor, Medicie SCAI Kawar Sigh Uiversity of Virgiia Health System, Cardiovascular Divisio SCAI Warre Maig Beth Israel Deacoess Medical Ceter, Divisio of Cardiology Professor, Medicie ad Radiology SCMR Geoffrey Bares Uiversity of Michiga Frakel Cardiovascular Ceter, Cardiovascular Medicie ad Vascular Medicie SVM Esther S.H. Kim Clevelad Cliic Staff Physicia, Departmet of Cardiovascular Medicie SVM Alex Auseo Ohio State Uiversity Medical Ceter Assistat Professor, Cliical Medicie, Divisio of Cardiology Cotet Reviewer, Academic Cardiology Sectio Leadership Coucil (cotiued o the ext page)

10 JACC VOL. 65, NO. 17, 2015 MAY 5, 2015: Halperi et al. COCATS 4 Itroductio 1733 APPENDIX 2. CONTINUED Name Employmet Represetatio Cosultat Speakers Bureau Owership/ Partership/ Persoal Pricipal Research Istitutioal/ Orgaizatioal or Other Fiacial Beefit Expert Witess Keeth Elleboge VCU Medical Ceter Director, Cliical Electrophysiology Laboratory Cotet Reviewer, Cardiology Traiig ad Workforce Committee Michael Emery Greeville Health System Cotet Reviewer, Sports ad Exercise Cardiology Sectio Leadership Coucil Bulet Goreek Eskisehir Osmagazi Uiversity Medical School Cotet Reviewer, Electrophysiology Sectio Leadership Coucil Bria D. Hoit Uiversity Hospitals Case Medical Ceter Cotet Reviewer, Cardiology Traiig ad Workforce Committee Howard M. Julie Adrew Kates Thomas Jefferso Uiversity Hospital, Jefferso Health System Cardiology Fellow i Traiig Washigto Uiversity School of Medicie Cotet Reviewer, Heart Failure ad Trasplat Sectio Leadership Coucil Cotet Reviewer, Academic Cardiology Sectio Leadership Coucil Kriste Patto Uiversity of Washigto Cotet Reviewer, Electrophysiology Sectio Leadership Coucil Robert Piaa Gregory Piazza Taveer Rab Vaderbilt Uiversity Medical Ceter Professor, Medicie ad Cardiology Brigham ad Wome s Hospital/Harvard Medical School, Cardiovascular Divisio Emory Uiversity School of Medicie Associate Professor, Medicie ad Cardiology/ Itervetioal Cardiology Cotet Reviewer, Itervetioal Coucil Cotet Reviewer, PVD Coucil Cotet Reviewer, Itervetioal Coucil Arash Sabati Childre s Hospital of Los Ageles Cotet Reviewer, ACPC Coucil David Vorchheimer Motefiore-Eistei Ceter for Heart ad Vascular Care Director, Cliical Cardiology; Professor, Cliical Medicie Cotet Reviewer, Idividual For the purpose of developig a geeral cardiology traiig statemet, the ACC determied that o relatioships with idustry or other etities were relevat. This table reflects peer reviewers employmet, represetatio i the review process, as well as reportig categories. Names are listed i alphabetical order withi each category of review. Please refer to for defiitios of disclosure categories, relevace, or additioal iformatio about the ACC Disclosure Policy for Writig Committees. ABIM ¼ America Board of Iteral Medicie; ACC ¼ America College of Cardiology; ACPC ¼ Adult Cogeital/Pediatric Cardiology; ASE ¼ America Society of Echocardiography; ASNC ¼ America Society of Nuclear Cardiology; HFSA ¼ Heart Failure Society of America; PVD ¼ peripheral vascular disease; SCAI ¼ Society for Cardiovascular Agiography ad Itervetios; SCMR ¼ Society for Cardiovascular Magetic Resoace; SVM ¼ Society for Vascular Medicie; VCU ¼ Virgiia Commowealth Uiversity. APPENDIX 3. ABBREVIATION LIST ABIM ¼ America Board of Iteral Medicie ABMS ¼ America Board of Medical Specialties ACC ¼ America College of Cardiology ACGME ¼ Accreditatio Coucil for Graduate Medical Educatio COCATS ¼ Core Cardiovascular Traiig Statemet