Demand overwhelms supply of cardiac CT training slots

Physicians who plan to perform cardiac CT are in for a surprise. Neither radiologists nor cardiologists are qualified to render diagnoses from multislice CT studies without undergoing more training. The supply of qualified teachers and training slots falls far short of the demands of users to learn this new technology.

Competence statements published by American College of Radiology and the American College of Cardiology Foundation have inadvertently created a logjam. The interim ACR statement requires radiologists to perform at least 75 cardiac CT studies (excluding calcium scoring) and receive at least 40 hours of Category 1 CME training in cardiac imaging to demonstrate competence to perform unsupervised interpretations.

The ACCF/AHA rules, which were developed by the American College of Cardiology Foundation, American Heart Association, and three other cardiology societies, established three levels of competence for physicians applying and teaching cardiac CT. To qualify to read unsupervised scans, defined as Level II competence, physicians must first interpret 150 studies under the guidance of a Level III-certified instructor and participate in the actual acquisition of 50 scans. Four weeks of coursework, continuing medical education, or online training are also required.

Yet most hospitals are not performing enough cardiac imaging to train physicians who want to meet these standards, according to Dr. Art Stillman, president of the North American Society of Cardiac Imaging (NASCI).

"If you look at the places that have fellowships, they are already saturated," he said. "You can't send hundreds of physicians out to get this."

By all indications, thousands of cardiologists and radiologists await training. The Society of Cardiovascular Computed Tomography (SCCT) attracted nearly 2000 physician members in the nine months after its formation in April 2005.

GE Healthcare faces the prospect of training more than 1000 physicians on its worldwide installed base of 64-slice LightSpeed CV scanners that are capable of cardiac imaging. Philips Medical Systems expects to teach 600 to 800 physicians in cardiac CT.

Nearly all of the more than 200 64-slice Siemens scanners in the U.S. are capable of coronary artery imaging, creating the need to educate several hundred physicians. Toshiba has 380 64-slice scanners worldwide. In the U.S., the firm is prepared to train 200 physicians.

Although the MSCT presentation of the coronary arteries is exquisite, the diagnosis of coronary artery disease based on interpretation of these images is not as easy as many physicians think. Interpretation and imaging manipulation and reconstruction are interrelated, according to Dr. John McB. Hodgson, chief of academic cardiology at St. Joseph's Hospital and Medical Center in Phoenix. Reading a scan involves a series of 3D and curved formats and sometimes axial images to confidently examine all segments that may contain coronary disease.

The challenges are different for cardiologists and radiologists, according to Dr. Norbert Wilke, director of cardiovascular MR and CT at the University of Florida, Jacksonville. Radiologists require more training in cardiac anatomy, physiology, and pathologic processes. Cardiologists must become accustomed to a different way of looking at the coronary arteries.

Postprocessing is an important component of Wilke's minifellowships. The lab is equipped with workstations from various vendors to give physicians daily hands-on postprocessing experience.

ASNC TRAINING INITIATIVES

Medical societies representing cardiologists have moved swiftly to introduce educational programs to bring their members up to speed.

The American Society of Nuclear Cardiology (ASNC) is sponsoring two-day weekend trainings in each of the first six months of 2006 to help nuclear cardiologists learn how to read cardiac CT scans.

The SCCT has become a clearinghouse of educational resources. It will sponsor "Cardiac CT: Read with the experts and test yourself" in Atlanta this month. In April, the SCCT will sponsor "Cardiac MR & CT: clinical update 2006 in Cannes, France." In May, it will join with the ACC and ASNC for a conference on advances in clinical nuclear cardiology and cardiac CT in Washington, DC. The first annual meeting of the SCCT in July will also emphasize educational programs.

Although the ACR has not yet become involved in educational efforts, several academic radiology departments and group practices have attempted to fill the gap. Cardiac imaging fellowships have been established at Massachusetts General Hospital and the University of Florida, Jacksonville. Johns Hopkins University is sponsoring "Cardiac CT: today and the future," a three-day conference in Atlanta this month. South Florida Medical Imaging in Boca Raton, FL, operates a two-and-a-half-day hands-on training program.

About 30 physicians have completed minifellowships in cardiac CT and MR at the University of Florida, Jacksonville, since 2003. Customized programs cover from three to 12 months of training, depending on physician need. Although a solid block of training works best, programs can be split into monthlong segments, Wilke said.

NASCI is planning an educational event for fall 2006. Association officials are discussing possible Web-based opportunities for supervised interpretation or audience response mechanisms at future conferences. They are also working with the ACR to come up with ways to increase opportunities for supervised interpretation, Stillman said.

The American Roentgen Ray Society sponsored a coronary CT angiography course in February. Other important providers of cardiac CT education for radiologists are Dr. David Dowe, medical director of Atlantic Medical Imaging in Galloway, NJ; Dr. Andre Duerinckx in Winston-Salem, NC; and Radiology Imaging Associates in Denver.

Vendors are supporting education in a big way. Siemens has more than 100 different types of cardiac training for its customers, including onsite training, online training, and various minifellowships, according to Scott Goodwin, CT division vice president. About 20 physicians per month receive classroom training in Cary, NC, and Salt Lake City. The company also has collaborations for physician training through Wilke's program in Jacksonville and with Dr. Michael Poon at Cabrini Medical Center in New York City, Dr. Thomas Brady at Massachusetts General Hospital, and Duerinckx at the Heart Imaging Center in Winston-Salem.

Philips plans to double its cardiology and radiology training sites in the U.S. to 10 by mid-2006, according to Philip Prather, director of cardiac CT. Didactic programs that were designed to allow physicians to meet ACCF/AHA and ACR guidelines are delivered online through Philips' proprietary Learning Center. Independent study is organized as 20-minute modules covering instrumentation, radiation exposure, x-ray physics, common artifacts, and anatomy.

Hands-on workshops can help physicians qualify for Level I ACC competency. Fifty supervised interpretations are completed during these two-and-a-half-day sessions. Level II training will be offered through the Cleveland Clinic and other Philips collaborators.

GE sponsors 40 cardiovascular CT programs for physicians and technologists at its healthcare institute in Waukesha, WI. Dowe oversees GE's Master's Course in cardiac CT. Those sessions can accommodate up to 18 physicians and are held twice a month.

Two-day cardiovascular training sessions for cardiologists underwritten by GE take place quarterly at Baylor Heart and Vascular Institute in Dallas, and monthly at Tennessee Heart and Vascular in Hendersonville and the Cardiovascular Medical Group of Beverly Hills in California.

Physicians will soon be able to search Teach CTA (www.teachcta.com) for more learning opportunities from GE. Online programs developed by Hodgson in Phoenix are designed to teach them how to interpret cardiac CTA exams.

"It is a unique opportunity for a customer sitting in the office or at home to go live on the Web and actually process cases," said DeAnn Haas, senior global cardiac product development specialist at GE.

In line with the ACCF/AHA and ACR guidelines, Toshiba has formed a partnership for physician training with Shands Hospital at the University of Florida, Gainesville; the University of California, Irvine; and the Cardiovascular Institute of the South in Houma, LA. The inaugural session at Shands in February featured five days of hands-on training preceding Web-based didactic training. Physicians attending the UC Irvine program will participate in up to 50 supervised scans during their week on campus, with eight weeks of periodic follow-up administered after they return to their practices. The three-day program in Louisiana includes clinical CV CT training and lessons in the business aspects of managing a cardiac CT business.

Mr. Brice is senior editor of Diagnostic Imaging.