Author + information
- aDivision of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- bSoutheastern Cardiology Associates, Columbus, Georgia
- ↵∗Address correspondence to:
Dr. Georges Ephrem, Division of Cardiovascular Disease, Department of Medicine, Emory University School of Medicine, 101 Woodruff Circle, Suite 319, Atlanta, Georgia 30322.
Two recent fellows in training (just graduated) express their views on the structure and duration of training. We welcome other opinions.
—Spencer King III, MDA year to learn it all. In the United States, the duration of interventional cardiology fellowship is 12 months as mandated by the Accreditation Council for Graduate Medical Education (ACGME). Interventional Fellows-in-Training (iFIT) should perform at least 250 procedures encompassing percutaneous coronary interventions including “the application and usage of balloon angioplasty and stents, along with Doppler flow, intracoronary pressure measurement and monitoring, coronary flow reserve, and intravascular ultrasound” (1). Additionally, iFIT provide comprehensive periprocedural care for patients during outpatient clinic visits. These requirements are essential as they provide a standardized minimum of competency. The tremendous expansion in the field of interventional cardiology raises valid concerns over the applicability of the aforementioned guidelines. Whereas the volume of percutaneous coronary interventions has reached a plateau (2), the prevalence of transcatheter percutaneous technologies spanning peripheral vascular disease and complex valvular heart disease is on the rise as more patients with prohibitive and moderate surgical pathologies previously treated medically are now included.
As such, calls have been issued to revisit the interventional cardiology fellowship training, including accreditation and funding for a 24-month program (3). Inasmuch as it is crucial to maintain training in phase with the development of the field, there are reservations regarding lengthening the training duration.
Discussions about additional years of training should be made with utmost delicateness. The published reports has described the conundrum faced by trainees in our field with longstanding debt, lengthening training, and decreasing income (4). iFIT are not deterred by the hazards of the job or the inconvenience of the lifestyle. They have persisted on this lengthy path for a desire to extensively but efficiently learn the arts and crafts of the subspecialty. Committed to lifelong learning, they are faced with the stretching of the training process. A 24-month program does not only entail another year of lower income—the estimated annual salary for a new interventional cardiologist being approximately 7× that of a second-year iFIT with similar qualifications (5)—it is especially additional time away from the job market at a period where positions are scarce. In several institutions with a dedicated second year of interventional training, 4 to 6 months are spent on service as part of the duties of a clinical instructor, effectively leaving the iFIT with only one-half a year of actual “hands on” time. No, the solution is in a more comprehensive, yet not longer, training.
A growing concern among iFIT pertains to the ACGME minimal requirements limiting the value of their interventional year. Examples of this trend can be found in the literature (3) where learning complex percutaneous coronary interventions and mechanical circulatory support is given as a reason for requiring an extra year. The numerous procedure types in coronary revascularization, from different plaque modification techniques to various circulatory support platforms, and the ever growing complexity of the lesions should be part of any 1-year interventional training whether or not they are specifically mentioned in the ACGME requirements. As for the structural and peripheral techniques, this is the most opportune time to make them officially an integral part of the interventional year. Given the trend in decreasing numbers of coronary interventions (2) and the consequent decrease in the numbers of fellowship training spots, enriching an interventional year with peripheral and structural technique acquisition would be a judicious use of the iFIT’s time.
Some might argue that there are too many procedures to be mastered in a single year of training because structural and peripheral interventions include a flurry of transcatheter therapies each with its own learning curve. From this perspective, the logic advocating an additional year of training may seem sound. However, the training paradigm is shifting (6) and so should our outlook. The glaring example for this new prism is the new COCATS (Core Cardiovascular Training Statement) promoting a philosophy of competency rather than number performed (7). Along similar lines, eminent educators in the interventional realm speak abundantly about training as acquisition of key skills sets (“the basics”) and the translocation of these core techniques between procedures (8). They refer to the first 3 to 5 years of clinical practice as the true “end of training” regardless of the intensity of exposure during fellowship. From this perspective, a comprehensive training can be achieved in 1 year. This would obviously require that training programs are conceived accordingly. For example, the outpatient experience should be a specialty clinic (interventional or peripheral or structural) that provides incremental education. If paperwork (e.g., admission notes, discharge summaries, prescriptions) and assistance in diagnostic procedures are monopolizing too much time, then proper delegation (midlevel providers, scrub technicians, and general cardiology fellows) should be implemented. Understandably, for a manager or an administrator, with a financial perspective and a tight budget, a second-year iFIT is the ideal option, especially when the estimated salaries for interventional nurse practitioners or physician assistants are 2× and 4× that of a trainee, respectively (5). The optimal training is that which provides a balanced “hands-on,” “first operator” experience to complement periprocedural patient care. If additional training is pursued, it should be to cross a qualitative threshold toward more “niche” career paths such as advanced heart failure and transplant or adult congenital heart disease.
As recent graduates from interventional training, we have a privileged position to view what is now and what we believe should be in the future. Interventional cardiology fellowship should be an intense, rich, 1-year-only training program focused on skills set acquisition in coronary, peripheral, and structural interventions. We rely on ACGME to continue advocating for trainees’ education. The optimal way to do so is not to give in to the trend in fragmentation of training by funding a 24-month curriculum but by updating its requirements to ensure fellowship programs provide the whole spectrum of skills acquisition. Once out of training, our commitment to lifelong learning as well as the mandated requirements for accreditation in the various devices or procedures will lead us to the refinement of our career path. This can be through the mentors, courses, or dedicated workshops. In a nutshell, more learning through a comprehensive, yet not longer, training: That is the future we long for.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Ephrem and Ibrahim are graduates of the interventional cardiology programs of Oakland University-William Beaumont School of Medicine and Emory University School of Medicine, respectively.
- American College of Cardiology Foundation
- ↵ACGME. ACGME Program Requirements for Graduate Medical Education in Interventional Cardiology (Internal Medicine). Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/152_interventional_card_int_med_2016_1-YR.pdf. Accessed August 17, 2016.
- Kalra A.,
- Bhatt D.L.,
- Pinto D.S.
- Ephrem G.
- ↵Peckham C. Medscape Cardiologist Compensation Report 2016. Available at: http://www.medscape.com/features/slideshow/compensation/2016/cardiology. Accessed August 17, 2016.
- Ibrahim A.W.
- Halperin J.L.,
- Williams E.S.,
- Fuster V.
- Ephrem G.