Introduction

Medical education is a recognized area of specialization, with an academic community and peer-reviewed journals. Occasionally, influential education research is published in general medical journals, but it is more typically confined to journals with medical education as their priority. Previous reviews have noted that education research has been traditionally weighted toward undergraduate medical education,¹ but changes in trainee duty hours, evolution in program accreditation, and the tenuous balance of federal funding with anticipated physician workforce shortages create a need for data-driven reform of graduate medical education (GME).^2,3

Cardiology fellowships are a specific cohort within GME programs. Due to the morbidity and mortality of heart disease, fellowship training in cardiology has a high potential for impact on population health in the United States. Cardiology is among the most prolific areas in medical research, producing new knowledge in clinical and translational science. In stark contrast, research describing educational innovations in cardiology appear to be rare. We hypothesize that few cardiologists engage in medical education research as their primary career interest, and that medical education research is rarely published in high-impact cardiology journals.

To serve as a needs assessment for the promotion of cardiology-specific medical education research, we (1) quantified medical education research published in cardiology journals; (2) quantified medical education research pertaining specifically to cardiology training; (3) quantified cardiologists participating in medical education research; and (4) estimated the priority of publishing medical education research within cardiology journals.

Methods

Compilation of Journal Lists

Two lists of journals arranged by impact factor (IF) were assembled in the fall of 2013. One list represented cardiology journals (CAJs) and the second was a combined list of general medical journals (GMJs) and medical education journals (MEJs). There are fewer journals in the MEJ category, and there is occasional crossover representation of education-themed articles in prominent general medical journals. The IF is derived annually from the June release of Thomson Reuters' Journal Citation Reports.⁴ IFs were compiled from the 2013 release of the Journal Citation Reports and reflected scores for the 2012 publications. The listings are seen in table 1.

table 1 Cardiology, General Medical, and Medical Education Journals Included in Search

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Results

Cardiologists as Authors in Medical Education Journals

Within the 25 GMJs and MEJs included in the search, there were a total of 5584 authors, with 697 (12.5%) in the GMJ group and 4887 (87.5%) in the MEJ group. In the total combined group, there were 128 cardiologists (2.3% of all authors). Of that cohort, only 25 cardiologists were among the 4887 total authors of medical education–themed publications (less than 1%). The complete representation of medical education authors can be seen in table 2.

table 2 Medical Education Authors and Their Areas of Medical Training

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Review of Cardiology Journal Mission Statements

There were 1036 total words included in the combined mission statements of each cardiology journal, and the top 50 keywords are displayed in the figure. The term “educational” appeared once, in the European Heart Journal. The top 5 keywords were “clinical” (used 27 times), “research” (22 times), “cardiovascular”/“disease” (19 times), “heart” (16 times), and “review” (10 times).

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Discussion

Cardiology is a prolific field within medical literature, but our data show that it appears to have largely ignored medical education scholarship. Within cardiology journals, there were exceptionally few education-themed articles in 2012, and only 1 journal mentioned education as a priority in their mission statement. Finally, the amount of cardiology-specific educational articles in general medical/educational journals and the number of cardiologists that were found to publish educational scholarship were very small.

Is it possible that cardiologists are not interested in education? This seems unlikely. National cardiology organizations routinely utilize physician volunteers for their educational committees and events, and cardiologists are frequently engaged in educational efforts at their institutions. This apparent conflict demonstrates an important distinction: that involvement in educational research and/or scholarship as a scientific career interest is separate from routine engagement in educational activities.

It is not known how many cardiologists focus on medical education as their primary research interest, but it appears to be a minority. One could postulate that cardiologists lack adequate mentorship, training, or resources to perform educational research. Currently, there is little training on how to conduct medical education research in most fellowship programs, and funding options for faculty with an educational focus are limited.^1,8,9 Education scholars in cardiology also may have difficulties publishing their work within their field. With the charter of flagship cardiology journals prioritizing novel manuscripts that have the potential to “impact the management of disease,”¹⁰ it is not surprising that the roughly 10% of submissions they accept do not contain many educational research manuscripts. Finally, the lack of medical education scholarship within cardiology does not appear to be a unique problem, as the findings for many other medical and surgical subspecialties appear similar (table 2).

One example that illustrates the need for education science in cardiology training is the recent update to the American College of Cardiology Core Cardiovascular Training Statement,¹¹ which serves as the outline for fellowship directors, the Accreditation Council for Graduate Medical Education, and the American Board of Internal Medicine as they structure, accredit, and certify cardiology training. It is a product that results entirely from expert consensus, rather than educational research. Though it has made great strides from its original draft in 1994, considerations such as the length of training in areas of cardiology and procedural volumes required for competency remain arbitrary.

This review of the literature has several limitations. Our technique of utilizing publicly available information was designed to answer a set of specific questions, but online search engines can be inaccurate, potentially leading to misclassification of data, such as an author's training background, and the medical specialty of 5% of the authors in our study was not known. The large amount of articles screened constrained our search to a review of titles in tables of content, rather than full articles, which may have led to some pertinent articles being missed. Finally, our study did not assess how many education-oriented manuscripts are received by cardiology journals and subsequently rejected during the review process.

Conclusion

In a review of all 2012 publications from the 26 cardiology, general medical, and medical education journals with the highest impact factors, there were very few cardiology articles with a focus on education, and very few cardiologists who published works of educational scholarship. In addition, flagship cardiology journals did not appear to prioritize education in their posted mission statements. These findings highlight the “cardiology gap” between the specialty's prolific clinical research and limited educational research.

We hope this will be a call to action for current and future cardiologists to engage in the exploration of medical education and the scholarship required in its necessary advancement. In raising awareness, we want to encourage cardiologists to pursue careers in medical education, and cardiology journals to review and accept their work. Initial first steps would entail consolidation of a focused community within cardiology, and identification of high-yield projects where research would advance the effectiveness of educational efforts. National organizations with education as their mission should collaborate with like-minded physicians and expert educators to provide resources and support.