Seeing the Big Picture: Training Today’s Imagers to ‘Think Multimodality’

Cardiologists are receiving more exposure to different imaging modalities during their fellowships, but their job prospects and training vary widely. A more comprehensive and multimodality training approach could lead to better results.   

As a cardiology trainee at Yale University, Gaby Weissman, MD, focused on echocardiography and nuclear cardiology, the two most common imaging modalities. After completing his fellowship in 2005, Weissman enrolled in a one-year program at Georgetown University and specialized in cardiac computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (cMRI). 

At that time, it was rare for aspiring imagers to have so much training in all four modalities. But these days, Weissman’s path is more common, as the emphasis on multimodality imaging continues to grow. Now, 67 programs in 24 states offer advanced imaging training programs, according to an online database compiled by the American College of Cardiology (ACC). 

Still, program lengths and curricula differ. The Accreditation Council for Graduate Medical Education (ACGME), American Board of Medical Specialties (ABMS) and American Board of Internal Medicine (ABIM) do not recognize imaging as an accredited subspecialty, either. And, across the country, there is debate about how to define multimodality imaging and how much expertise trainees need in each of the modalities before embarking on their career paths. 

In 2016, Weissman, Julie Damp, MD, of Vanderbilt University, and Chittur A. Sivaram, MBBS, of the University of Oklahoma, sent an online survey to each of the advanced cardiovascular imaging programs listed in the ACC’s database (JACC Cardiovasc Imaging 2017;10[9]:1080-1). In all, 19 programs responded, reporting they had a total 180 graduates during the previous five years. 

Of those graduates, 45 percent took a job primarily focused on imaging but also with clinical cardiology components and 42 percent worked in a role mostly focused on clinical cardiology but with some imaging responsibilities. Only 8 percent were entirely focused on cardiac imaging, while 5 percent were fully focused on clinical cardiology.

The graduates mentioned that expertise in echocardiography was required in 80 percent of the positions, whereas about half the jobs required expertise in nuclear cardiology, CCTA or cMRI. 

“The job market is a bit of a challenge because there is no one thing that places are looking for when they’re looking for a multimodality imager,” says Weissman, who is now a cardiologist and director of the cardiovascular MRI core laboratory at MedStar Washington Hospital in Washington, D.C. “There’s definitely an increasing need for these types of people in the sense that there’s a greater penetration of these modalities and there’s greater complexity of things being done. That’s trickling down throughout all levels of cardiology, but it’s just not a one-size-fits-all definition. There’s a reasonable amount of variability out there."

Growing interest in CCTA & cMRI

William Zoghbi, MD, director of cardiovascular imaging at Houston Methodist Hospital and a past ACC president, runs a two-year advanced imaging program at the Methodist DeBakey Heart & Vascular Center. The one candidate selected each year chooses the curriculum and receives training in echocardiography, cardiac SPECT, CCTA and/or cMRI. Houston Methodist also offers two other programs, one focused on cMRI and vascular magnetic resonance angiography and the other on echocardiography.

During the past few years, graduates of Zoghbi’s training program have been more interested in the newer fields of CCTA and cMRI than in the past. Zoghbi notes that not all centers offer specialized CCTA or cMRI training. Small practices often only offer echocardiography and nuclear cardiology, he explains, so prospective CCTA and cMRI imagers usually work in larger practices or academic centers. 

“We need to really dedicate the resources and the training and acknowledge [multimodality imaging],” Zoghbi says. “This is improving over time, but I think the more available it is, then you’ll be able to provide it to the trainees.”

As the healthcare system becomes concerned with lowering costs and measuring the quality of care, there will be greater expectations on imagers to have a base understanding of all four modalities, Zoghbi predicts. With this knowledge, they’ll be better equipped to suggest the best, most cost-effective test for diagnosing disease, recommending treatment options and managing conditions. And they may be less likely to default to the inefficient and often expensive approach of ordering multiple tests.

“I think in my mind, down the line as the field matures, that we’ll be talking about cardiovascular imaging in general as opposed to calling it multimodality,” Zoghbi says.

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Training multimodality imagers

The early versions of the ACC’s Core Cardiovascular Training Statement (COCATS) did not address multimodality imaging. But, in 2015, the authors of COCATS 4, including experienced and early-career imagers and a cardiovascular training program director, were charged with predicting how training would need to change to ensure that prospective imagers would excel as the field evolves. They recommended that all cardiovascular trainees should learn the advantages, limitations and potential risks of the four imaging modalities during the standard three-year training program and that cardiologists who want to become proficient in more than two imaging modalities typically will require additional training (J Am Coll Cardiol 2015;65[17]:1724-1906). 

Also in 2015, a group of imaging experts convened by the ACC concluded that technological developments are making it difficult for cardiologists to achieve high levels of expertise in all of the imaging modalities. Achieving such expertise could leave insufficient time for other general cardiology training and burden imagers with time-consuming and expensive requirements to maintain their credentials (JACC Cardiovasc Imaging 2016;9[10]:1211-23). 

It’s a good idea for cardiologists to be exposed to the different modalities, particularly if they want to work in practice and aspire to be independent readers in more than one area, according to Pamela S. Douglas, MD, a cardiologist at Duke University and the Duke Clinical Research Institute in Durham, N.C., who chaired the ACC’s meeting. 

Still, she says cardiologists shouldn’t be defined by the number of modalities they can perform, but rather by their level of competence in one or more modality. “Multimodality imaging in and of itself is not an appropriate goal,” Douglas says. “The goal is expertise in imaging. If, incidentally, you happen to be an expert in more than one modality, that’s great. But what’s important is the expertise.”

Ordering the right tests 

With the healthcare industry becoming more focused on value-based care, imagers in the future are going to have more responsibility to make sure they order the right tests for individual patients. As of now, though, there is a lack of data comparing the modalities, making it difficult to determine which is the best option in different circumstances. 

An important part of today’s training, says Zoghbi, is learning “to think multimodality imaging … what would be the best test to diagnose a disease or to treat somebody or follow somebody or for early detection. Now, you have many more choices than ever before. You don’t want to layer one test after another and another.”

Appropriate use criteria can help, telling cardiologists whether it’s appropriate to perform imaging tests in certain situations, but there are no algorithms or definitive guidelines to help imagers in every situation. To that end, researchers are conducting studies comparing the different cardiac imaging modalities. The goal is to provide imagers with more definitive information when they have to decide which tests to order. 

“One of the roles of the multimodality imager is being the gatekeeper, sort of understanding which are the right tests for the right patients and the right diagnoses,” Weissman says. “That becomes as important as actually performing the test and interpreting it.”