Cardiac CT training fills the gaps left by education and experience. Moreover, now is the right time to get it, as after 2010, a fellowship will be required. But costly tuition and poor reimbursement are keeping too many clinicians away.
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Cardiac CT is no longer new. In fact, as more 64-slice CT machines have penetrated the market, cardiac CT is new and improved. The technological advances came quickly—so quickly that though the technology is mainstream, instruction in its use has yet to become standard in medical school curriculums or resident training.
That will change and soon. At present, the ACCF (American College of Cardiology Foundation)/AHA (American Heart Association) Clinical Competence Statement on Cardiac CT and MR outlines a means to obtain credentials in cardiac CT that replaces education with experience. This path, however, may no longer be an option after 2010, the date for which the experience method of qualification is scheduled to expire. By then, medical schools and fellowships are expected to have incorporated cardiac CT education and training into their programs.
This original deadline was to occur in 2008. “It was extended to 2010, so it’s hard to know what will happen then—but that is the current status,” said John R. Lesser, MD, FACC, director of cardiac CT and MRI at the Minneapolis Heart Institute.
The extension gives physicians more time to obtain the proper credentials to perform cardiac CT exams and reads—time they may need. Few doctors have taken advantage of the opportunity to obtain credentials, which many attribute to economic factors. Out-of-pocket tuition and poor reimbursement for cardiac CT procedures discourage many physicians from pursuing cardiac CT-specific training.
Yet, this training is needed for anyone who does want to provide cardiac CT services. It fills in the gaps left by education and experience. “The benefit of formal training in cardiac CT is that one then achieves the ability, right, and certification criteria necessary to perform and read the studies. After 2010, a fellowship will be required,” said Robert A. Pelberg, MD, FACC, FAHA, FASE, FASNC, assistant professor of clinical medicine at the University of Cincinnati; director of the Regional Working Group of the Society of Cardiovascular Computed Tomography (SCCT); and director of echocardiography for the Ohio Heart and Vascular Center in Cincinnati.
The Development
Grandfathering physicians in prevents them from having to return to a fellowship, which was not an option when they were in training. Much of the cardiac CT technique was developed by early adopters. Improvements came with discussion among colleagues, particularly at conferences.
As more professionals became adept at performing and interpreting cardiac CT exams, some of them began to share their knowledge through lectures and courses. Conferences were organized by relevant societies, such as the American Society for Nuclear Cardiology (ASNC of Bethesda, Md), the Society for Cardiovascular Angiography and Interventions (SCAI of Washington, DC), and the North American Society for Cardiac Imaging (NASCI of Reston, Va).
Potential students for this coursework (then and now) include radiologists, cardiologists, and their respective fellows, as well as nuclear medicine specialists and CT technologists. “Internists are not excluded from training but have to meet certain criteria that qualify them to perform cardiac imaging,” said Pelberg.
The curriculum for each group varies. Radiologists already understand the science of CT but may need more training specific to the heart. “The average radiologist may not have been taught cardiac anatomy,” said John Rumberger, PhD, MD, FACC, director of cardiac imaging for The Princeton Longevity Center in Princeton, NJ. He believes that CT angiography involves more than looking at arteries for blockage or plaque—it also requires looking at heart function, including chambers and valves.
The focus of a radiologist’s cardiac CT training is, therefore, often not on the CT scanner but on cardiology-specific anatomy, applications, implications, and issues. “[Radiologists] don’t learn how to work the workstation so much, but they do have to learn what kind of information is usable for the physician ordering the test,” said Lesser.
Offering an example, Lesser said, “It’s not just telling the [ordering physician] that there is a 50% or 70% stenosis, but also taking the overall information and putting in the context of the patient’s history.”
Cardiologists don’t require additional education in this area, but they do need to be taught the physics of CT and image processing. “For cardiologists, we spend time on the three-dimensional cardiac anatomy seen on a CT but also focus on radiation and radiation safety, on how the image is generated, on how the CT scanner works, on what is needed for accurate diagnostic study, and on reconstruction and viewing techniques to aid in making a diagnosis,” said Pelberg.
“These programs are basically a place to obtain condensed information on a very specific and specialized technique that really, to date, has not been available in fellowship,” said Pelberg. Lecturers and mentors offer tips and tricks for image processing. Some items, such as 3D imaging or test appropriateness, may need to be covered in all coursework, no matter who the student.
“Many people just do not have any training on three-dimensional image processing, and it’s often what takes so long to train people to do. It’s like learning a new language. It’s very difficult to get people to think in three dimensions, yet it is an essential part of what we do in cardiac CT,” said Rumberger.
The Programs
How long it takes to learn this language varies with each individual. The ACCF/AHA Clinical Competence Statement suggests the minimum number of mentored examinations that a physician must perform to be considered competent in cardiac CT at level 2 is 50 exams each for contrast and noncon-trast techniques. To be certified at level 3, a physician needs to perform a minimum of 100 mentored examinations. At level 2, the physician must also interpret, under a mentor, a minimum of 150 cardiac CT images; level 3 requires 300 reads.
In addition, the guidelines specify the necessary experience needed to perform and interpret cardiac CT exams: non-contrast level 2 certification requires 4 weeks of training; contrast level 2 requires 8 weeks of cumulative training; and level 3 requires 6 months of cumulative training. Continuing education requirements must also be met, with level 2 physicians having to complete 50 cardiac CT exams a year and level 3 reading 100 annually.
“We stress in our course that certification does not equal competency, and we encourage students to continue to educate themselves and to not read until they feel competent,” said Pelberg. The competence criteria exist to help health care professionals achieve proficiency, but the point at which a professional does achieve proficiency will vary.
“Some get it at 50 cases, some at 125, and some, unfortunately, at 150. That’s just the way people are,” said Rumberger.
Mentors are integral to the process. “I think there is no possible way someone can learn complicated medical techniques without mentorship,” said Pelberg. Mentors provide the tips, constructive criticism, and oversight needed to ensure that learning physicians are competent to perform and read cardiac CT exams.
The Problems
Naturally, all of this takes time. That is one of the reasons why not as many physicians have taken advantage of this coursework as could—or should. “It’s expensive to take time away from work,” acknowledges Lesser.
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| Robert A. Pelberg, MD, FACC, FAHA, FASE, FASNC, and John Rumberger, PhD, MD, FACC. | |
Tuition is also expensive and may come out-of-pocket.
In some instances, the hospital or practice group may pick up the tab. In others, the CT vendor may provide the training as part of a purchasing agreement. “The CT company might provide training for a certain number of individuals from the buying institution,” said Pelberg. Ultimately, whoever wants the training will pay for it.
The fact, however, that current reimbursement for cardiac CT exams does not make up for the effort or cost of training leads fewer people to decide they want it. “In 2007, we started having more requests than we had [student] slots to fill, so we increased the number of training sessions. But in 2008, enrollment precipitously dropped and part of the problem was that there were initially threats from Medicare saying they weren’t interested in reimbursing for cardiac CT,” said Rumberger.
Physicians may be enthusiastic about cardiac CT, but if they are not paid adequately for the service, then there is little incentive (or little ability) to offer it, particularly when it does involve learning something new. “Most people who perform cardiac CT think it offers a lot and is interesting. They don’t do it to make money because it is not worth their time if that is the only motive,” said Lesser.
To learn a new technique while working in a busy private practice requires passion. Other routine exams can earn more money. Physicians may be leery of replacing higher-paid, more familiar techniques with a new modality that reduces reimbursement and the ability to “pay the bills.”
“It is fairly difficult for someone to purchase a CT scanner for cardiac studies and expect to pay for the machine and maintenance solely with cardiac studies,” said Pelberg. The scanner will often be used for other studies and/or may be shared among groups. If the economics can be worked out, the clinical value can be worth the expense and effort. Cardiac CT exams can help patients avoid invasive procedures, such as coronary angiography, and the potential for associated risks. Advanced CT technology features, such as 64-slice resolution and volumetric reconstruction, provide improved visuals that can help to identify problems before they manifest as symptoms. Patient care and outcomes may improve.
Training prepares practitioners to use these tools appropriately and accurately. Radiation exposure concerns mean that the use of CT should be carefully considered and not always assumed, another point addressed in cardiac CT training programs. Essentially, these programs help practitioners to avoid problems—if they have the means to deal with the economic “problems” associated with a cardiac CT program.
Renee Diiulio is a contributing writer for Axis Imaging News. For more information, contact .
