The cardiology SpR training curriculum is available here. It includes two sections: Core training and Specialist training. Relevant extracts are given below.
Cardiology Core training
3.4 Cardiac magnetic resonance (core) [mandatory assessment methods 4 (as part of other mini-CEXs) and 6]
|A basic understanding of the role of CMR and its capabilities, including the indications for its use.A basic understanding of how the procedures are carried out, in particular the safety issues.A basic understanding of image analysis, postprocessing and interpretation of images and data with emphasis on patient management.
|The indications and contraindications to CMR.The basics of CMR safety.The basics of CMR image acquisition.
The basics of CMR imaging protocols (anatomical imaging and functional imaging).The basics of CMR image processing.
The limitations of CMR.
|Plan and supervise the pre and post investigation management of CMR patients.Interpret clinical information and the results of other investigations to decide what information must be acquired by CMR.Interpret images from basic CMR sequences.Interpret CMR reports and their application to clinical management.
|Be aware of the limitations of noninvasive imagingAppreciate the importance of understanding cardiac anatomy in 3-dimensions.Have an appropriate threshold for seeking expert advice.Appreciate the importance of providing detailed information about the procedure and its potential complications to patients.Appreciate the importance of team work with radiologist, radiographers, anaesthetists and technical staff.
To achieve the learning objectives of core training for CMR it is envisaged that trainees will need a one month full time attachment (or equivalent part time). Appropriate learning methods are:
a) self directed learning
b) dedicated teaching by consultant staff (e.g. tuition by cardiologist or radiologist)
c) hospital meetings (e.g. departmental teaching, journal review, grand round presentations, study days, surgical conferences, radiology meetings)
d) local or national postgraduate education
e) apprenticeship learning
f) in-house specialist teaching material.
In order to gain sufficient experience to achieve the learning objectives it is recommended that the trainee will need: supervision of 10 stress tests, including each form of stress; observation of acquisition of 50 CMR scans, a minimum of 5 must be vascular; observation of processing of 50 studies; supervised reporting of 50 studies, including patients with: detection of myocardial infarction and assessment of viability; left/right ventricular function assessment; aortic/mitral valve pathology; aortic pathology including dilatation and coarctation; simple congenital heart disease; angiography of major artery abnormality. If clinical attachments to achieve these learning objectives are not readily available in all programmes, then the use of specific training days or secondments should be considered to allow trainees to acquire the training whilst a formal training programme is being developed.
Cardiology Subspecialty training
4.5 c Cardiovascular Magnetic Resonance (CMR) (Advanced)
Cardiovascular magnetic Resonance (CMR) uses radio waves and magnetic fields to generate static and moving images of the cardiovascular system. CMR is extremely versatile and has rapidly become a gold standard for the assessment of anatomy, cardiac volumes/function, blood flow and cardiac fibrosis/infiltration. CMR has moved from a tool used at a few luminary sites to an essential adjunct for most centres in the management of their patients. There is good evidence for the benefits of using CMR and many centres in the UK have plans to establish or expand such services. It has the following general advantages over other established imaging modalities: non-invasive; 3D reconstruction capability; non-ionising radiation; free from artefacts arising from bone and lung. Although all UK heart disease centres have access to MR scanners, some scanners have limitations in their cardiac imaging capability and there is a substantial lack of trained specialists who can provide a comprehensive CMR service.
Cardiac imaging is practised by a wide range of practitioners. Cardiologist, radiologists and nuclear medicine physicians have all played important roles in its development over the years. CMR shares this multidisciplinary heritage and many interested parties have developed substantial expertise. However, the fruitful combination of imaging and clinical expertise may not come together and in many centres the access to MR is severely limited by existing workloads and long waiting lists which greatly hinder the adoption of new techniques. Nevertheless, there has been considerable recent expansion of MR services in the UK and this should make the development of CMR easier as throughput pressures ease. In order to take advantage of these new possibilities, it is now vitally important that a cadre of well trained cardiac imagers specialising in CMR is available.
Core training is described in section 3.5.
Specialists who wish to run a CMR programme need a much more detailed knowledge of the subject. This extends to both the role of CMR in the management of a wide range of heart disease but also the technical aspects of how to obtain high quality of heart disease but also the technical aspects of how to obtain high quality information for all the different indications and how to process and report the scans.
Entry Requirements and duration of training
In order to utilise CMR the trainee must acquire a detailed understanding of the types of sequence available, the strengths and limitations of each sequence and the complex web of parameters which must be optimised for each sequence, all allied with an understanding of the physics of MR and how it impinges on the clinical process. This knowledge cannot be acquired during the core training. It is envisaged that a minimum of a one year programme of clinical training will be necessary in order to allow the trainee to independently manage a CMR service.
It is envisaged that entry to CMR sub-specialty training (advanced training) will be after completion of the core curriculum. It is assumed that the trainee will already have a detailed knowledge of the anatomy and physiology of a wide range of simple and complex heart disease before embarking on training in CMR.
Research and Audit
It is envisaged that trainees would undertake research and audit within the CMR department. The pursuit of a higher degree is desirable but not compulsory. Time spent solely in research may not count towards clinical competency in the sub-specialty but it is recognised that currently, in CMR, boundaries between clinical service and research are not always clear-cut.
It is envisaged that advanced trainees will be predominantly involved in the clinical provision of the CMR service. This will involve vetting of referrals for appropriateness and safety, organising CMR lists and liaising with other members of the CMR and cardiology teams. The trainee will oversee CMR lists and report on scans with supervision. It is important that, as trained clinicians, the trainees retain a close involvement with the clinical activities of the department. They should be closely involved with combined cardiology/imaging meetings, especially presenting CMR cases. Their on-call commitment should be adequate to meet continuing training requirements.
a) Self directed learning (e.g. textbooks, journals and internet sources)
b) Dedicated teaching by consultant staff (e.g. period of tuition by cardiologist or radiologist)
c) Hospital meetings (e.g. surgical conferences, radiology meetings)
d) Local postgraduate education (e.g. departmental teaching, journal review, grand round presentations)
e) Foundation courses and study days
f) Attendance (or presentation of research) at regional, national and international conferences)
g) Reflective commentary about anonymised patients in the portfolio of educational achievements
h) Apprenticeship learning (experiential learning)
i) Participation in research or audit supervised by consultant trainer
j) Participation in teaching
k) Participation in management
l) Use of in-house specialist teaching material
JRCPTB training record – This will document assessments carried out by training supervisors and may include evaluation by the trainee’s educational supervisor, another consultant, an allied health professional or an external assessor. The assessment may consist of:
i) direct observation of the trainee
ii) discussion with other staff members
iii) discussion with patients and their parents
In addition educational supervisors will:
1. Inspect the trainee’s portfolio of educational achievements (which should present evidence of a trainee’s progress in acquiring generic and clinical skills)
2. Inspect the trainee’s log book (which should record investigations or procedures performed by the trainee)
3. Evaluate the trainee’s critical reflection on events in clinical practice (the assessor should examine the trainee’s documentation of points learned from the care of individual patients).
These indicative levels of experience are compatible with international guidelines. It is unlikely that the Learning Objectives for advanced training would be achieved without the following experience:
Stress: Supervision of 20 stress tests, of which a minimum of 10 must be with each form of stress (vasodilator, inotrope).
Acquisition: Primary acquisition of 300 CMR scans, of which a minimum of 75 must be vascular.
Processing: Primary processing of at least 100 studies.
Reporting: Participation in the supervised reporting of 300 studies, with primary reporting of at least 100 studies, including patients with all of the following categories of pathology/clinical assessment requirement:
- detection of myocardial infarction and assessment of viability
- myocardial perfusion
- coronary anomaly
- left and rightventricular function assessment
- aortic, mitral, tricuspid and pulmonary valve pathology
- aortic pathology including dilatation and coarctation
- simple and complex congenital heart disease
- assessment of causation of heart failure
- assessment of cardiomyopathy phenotype
- pericardial abnormality
- cardiac mass/tumour
- angiography of major arteries including aorta, pulmonary, carotid and renal
|To equip the trainee to independently support all general aspects of a CMR service
|The imaging and functional characteristics of different congenital and acquired cardiac abnormalities.Indications for, and contra-indications to, the application of CMR MR physics and a basic understanding of the various MR sequencesComprehension of the various CMR sequences; their strengths, weaknesses and application and optimisation.Comprehension of various CMR protocols for different clinical application/disease entities.Understanding of CMR artefacts; their influence on interpretation and minimisation.Detailed knowledge of the different image processing tools both for analysis of functional data and for reformatting structural data.Practical knowledge of image formats; their characteristics and limitations and the ability to interchange data between them.Risks and complications of CMR.Safety in the CMR scanner suite
Relationship of CMR with other imaging modalities for complex physiological measurements and interventions.
The use of phantom models to assess CMR and measurement under controlled conditions.
|To be able to:Set up and organise a CMR serviceDevelop CMR study protocols for particular conditions and adapt them to specific patientsOptimise and acquire CMR sequences which provide the best image/functional information.Perform post-processing on CMR data for image presentation and quantification of physiological data.Interpret and report CMR structural and functional data.Provide training to radiographers and other clinical staff such as cardiology radiology trainees.Explain the physiology and pharmacology of pharmacological stress, including dobutamine, adenosine and dipyridamole.Define the indications and protocols for each form of stress and recognise complications and manage appropriately.
Describe current ALS guidelines.
|Appreciate the importance of good communication skills with other members of the clinical team as well as patients.Appreciate the importance of good organisational skills in running a CR service to ensure effective service delivery and in particular timely and accurate reporting / presentation of the scans.Appreciate the importance of understanding individual limitation and need for expert/outside advice.Appreciate the rapidly changing nature of CMR by keeping abreast of these changes optimising the service provided.
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