Forging education in preventive cardiology for the near future

This editorial refers to ‘The future of education in Preventive Cardiology: a statement of the European Association of Preventive Cardiology of the European Society of Cardiology’, by K.C. Koskinas et al., https://doi.org/10.1093/eurjpc/zwae259. The real dimension of prevention in medicine has been recently understood, in a wider context, allowing to think of increased well-being, quality of life, and reduction of cardiovascular (CV) risk, disease, disability, and early mortality. In this context, preventive cardiology has evolved, including not only CV primary and secondary prevention but also expanding to CV health promotion, forging behaviours, targeting a healthier lifestyle, involving nutrition, smoking cessation, exercise and sports, and looking at the different environments and socio-economic determinants, always considering people health, along the cycle of life, in a holistic perspective. This vision calls for different specialists, physicians, and other healthcare professionals, to accomplish many huge, multi, and interdisciplinary preventive tasks. Education for prevention, until now scattered in general cardiology, is now a focus of special attention, considering the integration of preventive cardiology education in a specific frame. This is actually one of the major focuses of the European Association of Preventive Cardiology (EAPC). During the EAPC Winter meeting in 2022, a workshop on education in prevention, involving participation of several experts, was a good opportunity to discuss this topic and to put preventive cardiology education into a modern perspective. Based on this workshop, an article was produced, identifying the needs for the educational offer in this area and the proposed strategies to shape it in the near future: ‘The future of education in preventive cardiology. A statement of the European Association of Preventive Cardiology (EAPC) of the ESC’.1 The EAPC, aligned with the European Society of Cardiology mission, which is to reduce the burden of CV disease, has already achieved some important resources for the educational offer in prevention, as the certification in preventive cardiology, based on the published core curriculum.2 This training curriculum for future specialists in preventive cardiology helps standardization and evaluation of cardiologists in CV prevention training across Europe, being the basis for dedicated fellowship programmes and EAPC subspecialty certification. This certification promotes a high-quality and less heterogeneous CV prevention in Europe, guaranteeing more favourable clinical outcomes. It also has the great value of covering not only physicians but also other healthcare professionals, facilitating the definition of roles in the various tasks and clarifying relations between the different professionals in multidisciplinary teams. Some educational resources need to be developed and added to the programme of preventive cardiology of EAPC, which is an ongoing process. There are already available books, being updated and translated, dynamic quizzes, various seminars, and congress presentations, but there is more to do. Still needing to be developed, a comprehensive preparatory course for the certification exam, including all topics, most probably with an online and an onsite component, can be important, motivating healthcare professionals to get certified and facilitating the success of certification, with well-defined modules covering the curriculum knowledge and skills areas and utilizing different learning methods. Regarding the learning methods, adaptation to modern needs and to contemporaneous people is obligatory. The learning methods are now shifting from the classic teacher-centred learning (or instructor-centred learning) to student-centred learning (or learner-centred learning) model,3 as addressed in the present consensus article.1 In the traditional model, based on the teacher approach, the teacher covers systematically all the topics through exhaustive communication of all programmatic contents with a passive attitude from the students. He or she is typically the leader of the lesson, the focus of attention, and the primary disseminator of information during the class period, responding to questions. The students expect guidance and feedback, with the teacher taking the central role in class discussions, limiting active student engagement to independent or group activities, with expected at-home tasks of reading textbooks or practicing concepts after the class. The classical perspective is learning at short term, but we do need long-term learning. The novel option is to substitute this model by an active support to students in exploring and understanding the topics, with active engagement in class interaction. Today, the new perspective of learning includes possibility of choice of some topics, research of contents, and a lot of interaction with teachers, who are mentors guiding all the learning process but not entirely responsible for it. Small group learning is promoted, for discussion and peer ideas exchange. In this important article,1 a ‘flipped classroom’ method has been proposed. This is an educational strategy and a type of blended learning, whose basic concept is to get at home what is the the usual class instruction, keeping the class time for activities (usually considered homework) wich require higher order thinking.4 Intentionally, it shifts instruction to a learner-centred model, in which students are often initially introduced to new topics before classes. The student is responsible for the initial approach to the content outside the classroom, using teaching resources (videos, online lectures, online discussions, readings, podcasts, or others) intentionally prepared or made available by the teacher for this purpose, with class time being organized to carry out more complex and interactive activities, such as problem-solving, group discussions, or projects. The teacher becomes more a ‘guide on the side’. After the initial preparation, class lecture time is free to have the knowledge into practice by the students with a mentor’s guidance. This pedagogical style moves activities into the classroom. Flipped classrooms also redefine in-class activities, which may include activity learning and problem resolution, among other practices, to engage students in the content. This model allows more time onsite at the classes for exploring topics in depth, creating learning opportunities, problem finding, and problem-solving, with collaboration of teacher and peers. A teacher’s interaction with students in a flipped classroom can be more personalized, more flexible, with students actively involved in knowledge acquisition and construction as they participate and evaluate their learning.5 An interesting model, inserted in this student- or learner-centred approach, the team-based learning (TBL),6 is a structured form of collaborative learning in small groups with elevated ratios of students/teachers. Individual work starts before class, and the acquired knowledge is applied in class in small groups with immediate feedback. The groups resolve cases and problems facing clinical scenarios. It is expected that students incorporate fundamental principles in the formulation of team solutions. It is also expected that students develop capacities in consequence of experiences of work team at the level of scientific content, scientific and clinical reasoning, attitudes and values, self-study, and providing and receiving feedback. When TBL is well implemented, students can progress considerably beyond simply acquiring factual knowledge and achieve a depth of understanding that can come only through solving a series of problems that are too complex even for the best students through their individual effort. This model fits well with the flipped classroom. In my view, a first part of the certification preparatory course, online, with different resources in a platform and the possibility of attending webinars with group interaction and a second part of the course, 1 week intensive onsite, mainly with case-based and problem-solving group discussion, led by experts, favouring interaction, would be a good choice, finishing with an online self-evaluation. But education for preventive cardiology is not only about models of learning contents. Education in preventive cardiology should cover topics, not only on knowledge but also on skills and competencies with a modern and correct methodology. It is fundamental to transmit to the certification candidates, the necessary characteristics to be present in those who will be preventive cardiologists: leadership, teamwork, empathy, advocacy competence, adherence to new technologies, applied knowledge, flexibility and adaptive behaviour, academic spirit, and education skills. The preventive cardiologist needs to be a good doctor, good educator, good communicator, good researcher, and a good advocate on prevention. The preventive cardiologist doctor, beyond scientific and technological knowledge, needs to have a strong human education, with true relational empathy with the patients and people in general, but also needs to know the evolving world and the environment and to look at it with a critical spirit, analysing the context in which patients are inserted. The physician needs to look at the patient as a whole, in a holistic perspective and, as Hippocrates, identify all variables to tackle for health balance. Educating for an effective relation is crucial. Physicians will need to acquire big confidence in transversal and interdisciplinary clinical practice to deal with other healthcare professionals with respect and empathy. Assuming particular importance for the preventive cardiologist is the central role of the patient in the relation patient–doctor. The doctor needs to face the patient in a true central role and promote conscious and shared decision, making patients able to do a better use of available healthcare and to understand how they can self-prevent CV disease. Also, it is fundamental to transmit to other healthcare professionals certificated in preventive cardiology, the importance of team work capacity, responsibility, and engagement, as well as the need, capacity, and skills to educate patients and families to self-care. Finally, we need to be aware that the programme of EAPC on Preventive Cardiology can be greatly designed, but only being inclusive, discussing and sharing it with all the National Societies of Cardiology in Europe, for motivation and adherence purposes, and promoting dissemination, preventive cardiology can move towards standardization and high-quality level, for the sake of better CV outcomes of our patients. The data underlying this article are available in the article and in its online supplementary material.