"Prevention and management of risk factors (for heart disease) is not an emphasized -- and almost neglected -- portion of the curriculum," said Dr. Quinn Pack, the lead author of the study. "We don't know how it affects (doctors') knowledge."

To become a cardiologist, physicians who have trained in internal medicine go through a cardiology fellowship lasting several years.

In 2008, leading organizations including the American College of Cardiology Foundation (ACCF), American Heart Association and American College of Physicians published recommendations that cardiologists in training get at least a month's worth of experience in settings devoted to prevention.

These could include clinics specializing in cardiac rehabilitation after a heart attack, diabetes treatment, weight loss, smoking cessation and other related topics.

Accreditation criteria for graduate medical training programs also require cardiology fellows to have training and experience in prevention-related issues.

Pack, who is a preventive cardiology fellow at the Mayo Clinic in Rochester, Minnesota, said he had noticed that some of the fellowship programs where he had applied seemed to emphasize prevention more than others.

To find out whether the fellowships are adhering to the training guidelines, Pack and his colleagues sent a survey to the directors and chief fellows of about 200 programs.

Less than a third responded, and among those who did, 24 percent of their programs met the guidelines for training in prevention.

Another 24 percent had no part of the curriculum formally dedicated to prevention.

While some prevention topics -- such as the use of heart medications -- were nearly always part of a formal lecture to fellows, other topics were overlooked.

The doctors who responded to the survey reported that nutrition, obesity, smoking cessation and managing chronic diseases each earned a place in a formal lecture less than half the time.

Dr. Roger Blumenthal, a professor at Johns Hopkins University who chaired the task force that wrote the ACCF training guidelines, said it was "very disappointing" that only a quarter of the programs set aside time in their fellowships for a rotation in prevention.

"What we would hope is that they're applying the basic preventive cardiology principles for the rest of their cardiology time," he told Reuters Health.

Pack said that in general the training recommendations have more of an emphasis on diagnosis and the management of acute heart conditions, and that fellows end up spending more time learning how to read stress tests and insert stents, for example.

Not only are these skills more technical than, say, helping people quit smoking, they can also earn doctors more money, Pack said.

"There tends to be more focus on the reimbursable procedures," Pack told Reuters Health, "as opposed to the things that, in my opinion, make a real difference to patients -- the medications, the diet, the smoking cessation and lifestyle changes."

Pack's study did not measure whether doctors whose fellowships followed the training recommendations were more knowledgeable in prevention than doctors who didn't get a dedicated prevention rotation.

The survey respondents often said that a lack of time to devote to prevention training was the biggest obstacle to meeting the guidelines.

Another problem was a lack of faculty members with expertise in prevention. Twenty fellowship programs had no faculty who specialized in the subject.

Blumenthal said the lesson learned from Pack's study is that program directors need to make sure their fellows properly understand all the fine points of prevention in cardiology.

Pack said getting prevention experts on staff and reconfiguring the fellowship program to include time for prevention could help programs meet the training recommendations.

"There's time," he said. "It's just given to other priorities."

SOURCE: bit.ly/K4162o The American Journal of Cardiology, online April 4, 2012.

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