Level 1 of Entrustable Professional Activities in adult echocardiography: a position statement from the EACVI regarding the training and competence requirements for selecting and interpreting echocardiographic examinations

Abstract

The goal of Level 1 training in echocardiography is to enable the trainee to select echocardiography appropriately for the evaluation of a specific clinical question, and then to interpret the report. It is not the goal of Level 1 training to teach how to perform the examination itself—that is the goal of higher levels of training. However, understanding the principles, indications, and findings of this crucial technique is valuable to many medical professionals including outside cardiology. This should be seen as part of a general understanding of cardiac imaging modalities. The purpose of this position statement is to define the scope and outline the general requirements for Level 1 training and competence in echocardiography. Moreover, the document aims to make a clear distinction between Level 1 competence in echocardiography and focus cardiac ultrasound (FoCUS).

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Introduction

Along with auscultation and electrocardiography, echocardiography has become an essential tool for every physician involved in providing care to cardiovascular patients. With technological improvements and miniaturization of devices, it has become possible to perform an ultrasound examination of the heart virtually everywhere, and both cardiologists and non-cardiologists are showing interest in using cardiac ultrasound as an adjunct to the physical examination. This basic type of point-of-care examination, known as focus cardiac ultrasound (FoCUS), provides bimodal (yes/no) answers to a set of predefined questions about cardiac morphology and function. It is typically performed by the physician responsible for the immediate decision-making and should be clearly differentiated from echocardiography.^1–3 Furthermore, cardiology often overlaps considerably with other medical specialties (oncology, pulmonology, endocrinology, etc.) so that the ability to interpret echocardiographic reports can also help non-cardiologists to better appreciate the cardiac consequences of underlying disease (e.g. diabetes mellitus, pulmonary hypertension, chronic obstructive pulmonary disease, etc.) and to guide decision-making (e.g. left ventricular function in a patient undergoing chemotherapy).

In parallel with wider use of echocardiography, cardiac computed tomography (CCT), cardiovascular magnetic resonance (CMR), and nuclear techniques have also become more readily available. As a result, the approach to the patient with known or suspected cardiac disease has become more patient-centred with diagnostic algorithms utilizing multimodality imaging.

However, it is not realistic that every physician accessing cardiovascular imaging will be able to independently perform and interpret all cardiac imaging modalities. Every physician referring patients for cardiac imaging should therefore know the benefits and the limitations of all imaging modalities and to be able to select the most appropriate one for a given patient.

The European Society of Cardiology (ESC) Core Curriculum for the general Cardiologist defines different levels of competence expected for skills related to investigations and procedures.^4,5 Cardiologists should be competent in all aspects of transthoracic echocardiography and be able to independently recognize the indication, perform, and interpret the examination.^4,5 On the other hand, the lowest level of competence (Level 1 of Entrustable Professional Activities) stipulates the level of experience needed for selecting the appropriate diagnostic modality and interpreting the results of examinations. Even though participation in echocardiographic examinations during training is encouraged, Level 1 competence in echocardiography does not include performing the examination itself.^4,5

The scope of this position paper is to propose training requirements for achieving Level 1 competence in echocardiography (ability to observe, select, and interpret echocardiographic examinations) in accordance with the ESC Core Curriculum for the general cardiologist.

The objectives of the document are:

1. To align training requirements for Level 1 echocardiography with other imaging modalities (CCT, CMR, and nuclear techniques);

2. To provide an education and training framework to reach Level 1 competence in echocardiography;

3. To make a clear distinction from Level 1 training and competence in echocardiography and FoCUS.

Levels of competence in echocardiography

Both the ESC Core Curriculum for the general cardiologist and the EACVI recommendations on training and competence in echocardiography were updated in 2020.^5,6 Instead of three levels, the ESC Core Curriculum now proposes five levels of Entrustable Professional Activities (EPAs), where EPA is defined as a unit of professional practice the trainee can execute in an independent manner at some stage of training.⁵ The comparison between the current and previous classification of levels of competence is shown in Table 1.

Since there are no essential differences between the definitions of Level 1 and EPA 1, the term Level 1 in this document will also refer to EPA level 1.

In order to avoid confusion with terminology, Level 1 competence in echocardiography should not be referred to as basic training or basic level of competence in echocardiography. In the recent update of recommendations on training and competence in echocardiography, the EACVI retained the two levels of competence and training in echocardiography: basic and advanced.⁶ In contrast to Level 1 training in echocardiography, the basic level of echocardiography enables the trainee to independently perform the general transthoracic echocardiographic examination (TTE) upon the completion of training.

The advanced level training in echocardiography enables the trainee who already completed the basic training to become fully competent in special echocardiographic techniques such as strain, 3D, contrast, stress, or transoesophageal echocardiography (TOE).⁶

Level 1 training and competence in echocardiography: definition and target population

Definition

Level 1 training in echocardiography enables the trainee to understand the applications and limitations of echocardiography, to appropriately select echocardiography for evaluating a specific clinical question, and to interpret the echocardiographic report. Level 1 training is not sufficient for the practice of echocardiography under any circumstances.

Target population

Since general cardiologists are expected to reach full competence in all aspects of echocardiography and to perform the technique independently, Level 1 training in echocardiography is primarily intended for non-cardiologists involved in the management of patients with cardiovascular disease (Table 2). In the first place, this applies to cardiac imaging specialists (radiologists and nuclear medicine specialists) fully trained in CMR, CCT, or nuclear techniques but without the intention of becoming fully conversant with echocardiography. Non-cardiologists involved in the multidisciplinary fields or programs in which echocardiography plays an important role in decision-making could also benefit from Level 1 training in echocardiography. For instance, an oncologist could benefit from understanding advantages and limitations of different echocardiographic indices for the assessment of left ventricular systolic function, as well as other echocardiographic parameters indicating cardiotoxicity of oncology treatments. In a similar way, a pulmonologist could benefit from understanding the principles, accuracy, and limitations of non-invasive assessment of right heart pressures and right ventricular function.

General practitioners with a special interest in cardiology could also benefit from this type of training, especially in terms of understanding indications for echocardiography and becoming competent for basic interpretation of the echocardiographic report. Finally, Level 1 training in echocardiography should be open for all medical professionals with an interest in echocardiography and cardiovascular medicine, for clinical or research purposes.

Training requirements for achieving Level 1 competence in echocardiography

Recognizing the heterogeneity of the target population and considering national differences across Europe, we propose two different tracks for achieving Level 1 competence in echocardiography for medical professionals at different levels of training or with different backgrounds (Figure  1). Completion of either formal or course-based training is the only requirement for certification in Level 1 echocardiography.

Formal training incorporates Level 1 training in echocardiography into formal residency and fellowship programs (usually cardiology, internal, and emergency medicine). Where applicable (i.e. cardiology fellowship), Level 1 training in echocardiography may be a valuable introductory step towards full competency in echocardiography. The trainer should be an independent operator (EPA 5, Level 3 in TTE) who preferably holds EACVI certification in echocardiography or corresponding national certification. On top of theoretical training, the trainees should be exposed to at least 50 echocardiographic cases/examinations. Practical training in conventional TTE examinations is encouraged, but it is not mandatory. If the fellowship program does not result in achieving the competence to perform echocardiographic examination, the completion of Level 1 training in echocardiography should be documented by issuing a certificate by the director of the program, supervisor, or mentor.

Course-based training involves obtaining Level 1 competency in echocardiography by attending one or more dedicated Level 1 training courses (e.g. on-site events, online video tutorials, webinars, e-learning platforms, etc.).

Appropriate coverage of the educational objectives typically requires at least 2 days of dedicated Level 1 onsite courses. In the case of e-learning, the duration of the educational content should be equivalent to the duration of onsite events/sessions. All topics/modules should be completed within the timeframe of 1 month.

Course-based trainers should have the same competencies in echocardiography as required for formal training (EPA 5, Level 3 in TTE). A certificate should be issued upon completion of all course modules, and this should be accompanied by an appendix describing the course curriculum.

For both formal and course-based training, the educational content should at a minimum include the topics listed in Table 3. While Level 1 training mostly pertains to TTE, indications, advantages, and limitations of TOE, stress, and contrast echocardiography should also be included in the course program.

Educational content, especially in the case of online learning, needs to be systematically updated at regular intervals to keep it up-to-date. The release of major ESC/EACVI guideline updates should be followed by online educational resources covering the corresponding topics (e.g. chamber quantification, valvular heart disease assessment, etc.).

Generally, Level 1 training should not be focused on technical aspects, but rather on feasibility, reproducibility, and accuracy of echocardiographic methods and parameters and their relationship with other imaging techniques.

Although course completion is the only requirement for certification in Level 1 echocardiography, post-course multiple-choice tests are encouraged to assess the knowledge and understanding of trainees.

An official EACVI certificate will be issued only to trainees who completed onsite or online training organized by or officially endorsed by the EACVI.

The requirements for achieving Level 1 competence in echocardiography have been aligned with those for achieving Level 1 competence in CMR and CCT, proposed by the EACVI and other imaging societies.^6–9

Level 1 echocardiography vs. FoCUS

The availability and mobility of ultrasound devices and the important information they can rapidly provide make point-of-care cardiac ultrasound examinations attractive to many non-cardiologists. It is likely that semi-automated image acquisition and interpretation, empowered by machine learning and artificial intelligence, will lead to further dissemination of these echocardiographic approaches.

FoCUS is defined as a point-of-care cardiac ultrasound examination, performed according to a standardized, but restricted, scanning protocol, as an extension of the physical examination.^1,2 FoCUS is usually performed by non-cardiologists not fully trained in echocardiography but appropriately trained in FoCUS. Although it may seem that Level 1 competence in echocardiography and FoCUS are related, it should be emphasized that these two types of training are completely distinct (Table 4).

There are two noticeable differences between the Level 1 training and FoCUS: the scope of training and the obtained competencies. Level 1 training enables the trainee to understand the utility of echocardiography but not to perform the examination. On the other hand, FoCUS enables the trainee to perform a restricted scanning protocol in patients who are typically unstable in order to make critical real-time decisions based on the results of the examination. Since the level of responsibility is diametrically opposed, the requirements for training and certification in Level 1 echocardiography and FoCUS are strikingly different. While the mere exposure to the technique may be sufficient for certification in Level 1 echocardiography, the training in FoCUS must include the practical part with a proctor to obtain the skills for performing the examination in the emergency settings. The EACVI have already proposed a Core Curriculum for FoCUS,¹ while the certification and accreditation in FoCUS are underway.

Finally, although theoretical knowledge from Level 1 training may be valuable to anyone interested in echocardiography, healthcare professionals interested in performing FoCUS must undergo the training that is tailored for this type of examination.

Conclusions

Level 1 competence in echocardiography does not enable medical professionals to perform echocardiography, but it provides essential knowledge about the appropriate indications, the diagnostic potential, and the limitations of this indispensable cardiac imaging modality. Obtaining Level 1 competence in echocardiography will give a broader picture to a wide range of medical professionals who do not need to acquire the skills to perform echocardiographic examination, but who regularly come across echocardiography in their daily practice and need the knowledge to use it for improving patient care.

Data availability

No new data were generated or analysed in support of this research.

Funding

None.

Conflict of interest: None to declare.

References