BSCMR Guidance for Core and Advanced CMR training
(2010 Update, Cardiology)
1Introduction
The May 2010 cardiology SpR training curriculum (downloadable here) includes 2 CMR sections: Core and Advanced training. This document serves to provide further guidance and useful tools for trainees and trainers in CMR. It should be seen as an adjunct to the current SAC/JRCPTB curriculum for cardiology approved by the GMC GMC curriculum for cardiology. For the version and writing group, see appendix 4.
The core and advanced training requirements are outlined below and mirror the recommended experience, knowledge and behaviours outlined in published UK curricula. They reflect current International best practice in CMR such as and those outlined in the US Taskforce criteria for training in CMR at Core training is the equivalent to level 1 clinical competence. This level does not qualify a trainee to perform or interpret CMR independently. Advanced training in the UK aims for the equivalent of the internationally defined level 3 clinical competence. This should enable those who have successfully completed their advanced training to have the expertise to direct and run a CMR service. It is acknowledged that an intermediate level of competence exists that allows trainees to perform or interpret CMR independently within a unit where there is at least one individual with level 3 competence, the equivalent of level 2 clinical competence. This is not covered in this document and within the UK this level of experience does not conveniently fit within the classification of core and advanced training.
Furthermore this document parallels Cardiovascular CT (CCT) training to a large extent and includes hyperlinks to both UK (British Society of CMR (BSCMR)) and International (Society of CMR (SCMR)) guidelines – so is best read electronically. For the version and writing group, see appendix 2. This document espouses the value of competency-based assessment underpinned with a recommended minimum experience for core and advanced training.
2Core training
Details of the BSCMR recommendations for core training are outlined in this document and should be read in conjunction with the 2010 cardiology curriculum.This document offers more detail on the recommended experience, knowledge and behaviours that will allow trainees to demonstrate acquisition of the required competencies. It is acknowledged that most hospitals performing CMR in the UK only do one or two CMR lists a week, making a definitive time requirement to gain the necessary experience problematic, particularly in the short term. BSCMR provides a useful checklist for core training inappendix 1.
There is additional guidance for the national delivery of core CMR training contained within a separate BSCMR document. The following offers a brief summary of the current guidance.
Core CMR Requirements for 2010 Curriculum:
To have a basic understanding of the role of CMR and its capabilities including its indications.
To have a basic understanding of how the procedures are carried out, in particular the safety issues.
To have a basic understanding of image analysis, post-processing and interpretation of images and data with emphasis on patient management.
Demonstrate knowledge of:
Indications and contra-indications to CMR
Basics of CMR safety
Basics of CMR image acquisition and image processing Exam
Basics of CMR imaging protocols (anatomical imaging and functional imaging)
The limitations of CMR
Demonstrate the ability to (CMR specific)
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
Demonstrate the ability to (role of advanced cardiac imaging):
Awareness of the limitations of non-invasive imaging
Appreciation of the importance of understanding cardiac anatomy and an appropriate threshold for seeking expert advice
Appreciation of the importance of providing detailed information about the procedure and its potential complications to patients
Appreciation of the importance of team work with radiologists, radiographers, anaesthetists and technical staff
To achieve these objectives the following is recommended:
1)1 month attachment to a CMR unit to obtain core didactic knowledge
2)Observation of 50 CMR scans (with 10 stress tests, including each form of stress)
3)Supervised processing/reporting of 50 studies
The following methods can be used to achieve core competency in CMR:
1)Didactic CMR modules- taught and online resources
2)Clinical CMR cases- directly observed and use of online libraries
3)Attendance at sessions at a dedicated CMR unit
2.1Core trainingadditional BSCMR Recommendations:
Although not mandatory, core trainees should consider attendance at one or more of the meetings outlined in Section 4.1, particularly for those considering undertaking advanced training. Additionally BSCMR recommends certain courses, self directed learning resources, online reading and books (see Section 4).BSCMR provides a useful checklist for core training, appendix 1.
3Advanced training
UK advanced training in CMR aims to give trainees competence to run a CMR programme. This is the equivalent of the internationally defined level 3 clinical competence as described in the US Taskforce criteria for training in CMR( To achieve this level of competence trainees need a much more detailed knowledge of the subject of CMR and importantly other cardiovascular imaging modalities. 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 information for all the different indications and how to process and report the scans.
The advanced training requirements are outlined here and mirror those international guidelines for training in US Taskforce criteria for training in CMR at
To gain advanced competence in CMR, trainees having completed core specialty training are likely to need:
a)12 months experience devoted to CMR training (in a high volume CMR centre)
b) 12 months additional experience concurrent with other cardiovascular imaging training
c) Protocol involvement at time of acquisition of at least 100 studies.
Supervised reporting of at least 300 studies of which,
Primary reporting of at least 100 studies
Reporting of a minimum of 75 vascular cases
Supervision of a minimum of 20 stress tests
10 using vasodilator
10 using inotropes
The case mix should ideally include:
- detection of myocardial infarction and assessment of viability
- myocardial perfusion
- coronary anomaly
- left and right ventricular 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 (aorta, pulmonary, carotid, renal)
d)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
e)Clinical role
- Be predominantly involved in the clinical provision of the CMR service.
- Vetting of referrals for appropriateness and safety,
- Organising CMR lists
- Liaising with other members of the CMR and cardiology teams.
- Oversee CMR lists
- Report on scans with supervision.
- Retain a close involvement with the clinical activities of the department, including audit and other quality assurance programmes.
- Close involvement with combined cardiology/imaging meetings, presenting CMR cases.
- On-call commitment should be adequate to meet continuing training requirements.
f)CMR research presented at regional/national meetings or published in peer reviewed journals
Additional desirable attributes include:
g)a higher degree involving CMR
h) SCMR Level 3 Accreditation
Recommended learning methods are:
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
3.1Assessment Methods
The JRCPTB training record will be used to document assessments carried out by trainingsupervisors and may include evaluation by the trainee's educational supervisor.These should be available for ARCP or equivalent as required. These assessments should consist of:
i) direct observation of the trainee by trainers
ii) feedback from other staff members
iii) feedback from patients and/or their carers/parents
In addition educational supervisors will:
a. Inspect the trainee's portfolio of educational achievements (which should present evidence of a trainee's progress in acquiring the necessary knowledge, generic and clinical skills, and experience)
b. Inspect the trainee's log book (which should record investigations or procedures performed by the trainee)
c. 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).
New methods of assessment MSF, Mini-CEX, DOPs, CbD and PSS
New methods of training and assessment have been introduced to allow a more structured approach to assessing trainees’ competency. Below are outlined BSCMR recommendations for the CMR specific component of advanced cardiac imaging training. The 5 components of the new methods of training are DOPS (directly observed procedural skill), 360 degree assessment and Mini-CEX (clinical evaluation exercise), CbD (Case based Discussions) and PSS (patient satisfaction survey).
These should be used in conjunction to the traditional methods, such as maintenance of a logbook as outlined in the current guidelines, and be part of the 3 monthly supervisor appraisal processes that contributes to the Training Director’s assessment and report. A 360 degree Multi-source feedback should be performed as per JRCPTB guidelines. A PSS should also be performed as per current JRCPTB guidelines. These form part of the overall training requirements for trainees in UK advanced training. For CMR there follows guidance for CMR specific DOP’s and CbD’s which may be useful to achieve the overall requirements for workplace based assessment during advanced training.
3.1.1DOPS
Assess the ability to correctly perform a technical procedure. Reference is made to the SCMR standardised acquisition protocols, JCMR, 2008, 10:35. It is important that trainees develop a portfolio of DOPS to demonstrate their competence. Whilst in some cases this may be limited by local practice, trainees should consider training opportunities in other CMR centres to maximise their exposure to a broad range of clinical scenarios. For each of the points outlined in each DOP the trainee is given a score between 1 and 9 as outlined below:
A score of 1-3 is considered unsatisfactory, 4-6 satisfactory and 7-9 is considered above that expected of a trainee at the same stage of training and level of experience.
A score of 1-3 should be justified with at least one explanation/example in the comments box; failure to do so will invalidate the assessment. Anchor statements will indicate the degree of independence that the trainee has demonstrated i.e. Level 1 – able to perform the procedure under direct supervision/assistance, Level 2 – able to perform the procedure with limited supervision/assistanceLevel 3 – competent to perform the procedure unsupervised and deal with complications. Additional comments and other relevant opinions about this doctor's strengths and weaknesses are welcome. Further guidance for DOPs can be found on the JRCPTB website here.
BSCMR recommended DOPS:
1)Resting ventricular function
2)Late gadolinium enhanced imaging
3)Flow
4)Stress imaging/perfusion
5)Angiography
The generic DOP’s form should be used in each case. This is either available online via or can be accessed directly via a trainees e-Portfolio.
In more detail, DOPS should cover the following areas:
1) DOPS: Resting ventricular function:
a)Interacts appropriately with patient
b)Able to position patient within MRI scanner with due regard to safety
c)Appropriate piloting and sequencing
d)Able to adjust scanning parameters to optimise image quality
e)Obtains 4 long axis cines and SA cine stack
2) DOPS: Delayed enhancement imaging
a)Interacts appropriately with patient
b)Able to position patient within MRI scanner with due regard to safety
c)Appropriate piloting and sequencing
d)Obtains long axis views and a short axis stack of images
e)Demonstrates ability to set appropriate inversion times
f)Able to adjust gating to obtain diagnostic images for tachycardic and bradycardic patients
g)Uses ‘phase swapped’ images/cross cuts to verify presence/absence of late gadolinium enhancement
h)Able to image for thrombus or microvascular obstruction (if appropriate)
3) DOPS: Stress testing (dobutamine or adenosine):
a)Interacts appropriately with patient
b)Obtains appropriate consent/adequately explains procedure/aware of contraindications
c)Knowledge of the side-effects and their treatment of stress in an MRI environment
d)Able to position patient within MRI scanner with due regard to safety
e)Obtains appropriate pilot images, long axis cines and SA cine stack
f)Able to perform progressive stress
g)Acquires appropriate views with optimised parameters
h)Able to terminate the test appropriately
i)Able to interpret and report images appropriate to the clinical context
4) DOPS: Angiography
a)Interacts appropriately with patient
b)Able to position patient within MRI scanner with due regard to safety
c)Appropriate use of transaxial single shot bright and black blood imaging
d)Appropriate use of additional plane brightand black blood imaging, including 3 point piloting
e)Correctly times contrast bolus
f)Able to post process images (subtraction, MIPS, MPR)
5) DOPS: Flow
a)Interacts appropriately with patient
b)Able to position patient within MRI scanner with due regard to safety
c)Appropriate piloting for aortic/pulmonary/other through and in-plane flow for stenosis, regurgitation and QpQs
d)Appropriate use of flow sequences including VENC adjustment
e)Appropriate analysis for peak velocity, flow, QpQs
3.1.2Case Based Discussions:
Case-based discussion (CbD) test the ability to interpret the images and then to relate these findings to the appropriate clinical context. CbD is designed to assess clinical decision-making and the application or use of medical knowledge in the interpretation of CMR studies, and, to a lesser extent, report writing. As with DOPS, it is important that trainees develop a portfolio of CbDs to demonstrate their breadth of understanding of the subject. Further guidance for CbD’s can be found on the JRCPTB website here. As local clinical experience may be limited, trainees should consider training opportunities in other (regional) CMR centres to maximise their exposure to a broad range of clinical scenarios.
BSCMR recommended CbD’s:
1)Resting ventricular function
2)Valvular heart disease
3)Ischaemic heart disease (viability and ischaemia)
4)Pericardial disease/cardiac masses
5)Non –Ischaemic Cardiomyopathy (including HCM, ARVD, DCM and myocarditis)
6)Congenital Heart Disease
The generic CbD form should be used in each case. This is either available online via or can be accessed directly via ePortfolio. In detail, the types of area to be assessed are described below.
1) CBD: Resting Ventricular Function
a)Demonstrates the ability to recognise normal and abnormal myocardial anatomy
b)Correctly identifies regional and global myocardial dysfunction including hypokinesis, akinesis and dyskinesis
c)Understands the principles of volumetric analysis and comparison between imaging modalities
d)Able to correctly calculate LV volumes (and RV volumes where appropriate)
e)Ability to use at least one analysis package, and awareness of problem areas (eg basal slices)
f)Able to correctly interpret volumetric data
g)Uses appropriate reference ranges (for imaging and analysis used)
h)Able to write an appropriate and cogent report that is relevant to the clinical problem
2) CBD: Valvular Heart Disease
a)Understands the principles of valvular assessment and comparison between other imaging modalities
b)Understands normal valve anatomy and function
c)Can accurately describe abnormalities of valvular anatomy and mechanisms leading to valvular dysfunction
d)Able to calculate peak velocities, valve areas and regurgitant fractions
e)Able to write an appropriate and cogent report that is relevant to the clinical problem
3) CBD: Ischaemic heart disease
a)Able to interpret images appropriate to the clinical context
a)Knowledge of the side-effects and their treatment of stress in an MRI environment
b)Appropriate use of stressor to answer to answer clinical problem
c)Able to correctly interpret resting LV function data
d)Able to correctly interpret Late Gadolinium Enhancement data
e)Able to correctly interpret Dobutamine stress imaging OR Adenosine perfusion imaging
f)Constructs report using either the AHA 17 segment model or related to coronary artery territories as appropriate
g)Correct use of the terms, normal, viable, hibernating, ischaemic
h)Able to write an appropriate, cogent report that is relevant to the clinical problem
4) CBD: Non-ischaemic Cardiomyopathy (including HCM, ARVD, DCM and myocarditis):
a)Able to interpret images appropriate to the clinical context
b)Correctly identifies cardiomyopathy phenotypes and ‘normal’ variants
c)Appropriate use and interpretation of various imaging techniques (eg Late gadolinium, STIR etc)
d)Correctly interprets patterns of late gadolinium enhancement in diagnosis
e)Able to write an appropriate and cogent report that is relevant to the clinical problem
5) CBD: Congenital Heart Disease
a)Appropriate description of cardiac, great vessel and major organ anatomy
b)Can accurately identify the common simple and complex congenital heart disease abnormalities/syndromes
c)Can accurately describe abnormal cardiovascular anatomy and function in rare complex congenital diseases
d)Appropriate calculation of LV and RV volumes (as appropriate)
e)Appropriate calculation of flows, shunts and regurgitant fractions
f)Able to correctly identify significant valvular disease