Author + information
- Ryan J. Maybrook, MD∗ ()
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital & Medical Center, Kansas City, Kansas
- ↵∗Reprint requests and correspondence:
Dr. Ryan J. Maybrook, Division of Cardiovascular Diseases, University of Kansas Medical Center, 3901 Rainbow Boulevard, Room 1001, Eaton, MS 3006, Kansas City, Kansas 66160-7200.
When I was recently being patted down by a Prometric employee before walking into the test room for my third board certification examination in my final year of cardiovascular fellowship, I began to ask myself, “what kind of career did I sign up for?” I thought board examinations ended shortly after medical school. “Will my future career consist of expensive board review courses and endless recertification exams?”
At your local Build-A-Bear Workshop, the more you pay for your teddy bear and add-ons, the more attractive your animal looks. In my opinion, this is not unlike becoming a cardiologist today, in which you can literally pay for “add-ons” to look more appealing to patients, colleagues, and hospitals. These add-ons include anything from board certifications, obtaining fellowship status in various societies and organizations, and securing the current maintenance of certification designation. From the perspective of a fellow-in-training (FIT), there are pros and cons to the plethora of board certifications, with their attendant board examinations, that are currently offered to today’s FITs and cardiologists.
The American Board of Internal Medicine was established in 1936, and cardiovascular diseases was officially recognized as a subspecialty in 1941, when the first board examination was administered in oral format (1,2). The last 15 years have seen a dramatic increase in the subspecialization within the field of cardiology, and this trend will likely continue, as stated in a review written by Dr. Eugene Braunwald near the turn of the century (3). Currently, the American Board of Internal Medicine offers the general cardiovascular disease examination in addition to added-qualification examinations. Also, various subspecialty (society) board examinations/certifications have appeared over the years (Table 1). Last, there are other certification examinations that are offered to other specialists. For instance, the American Society of Hypertension Qualifying Examination for Specialists in Clinical Hypertension is also offered to nephrologists and endocrinologists.
Pros and Cons
Although FITs and most early career cardiologists are seemingly locked into this new philosophy within mainstream cardiology, there is a trend within cardiology, mainly by those who have been in practice for some time, to oppose the new expectations. Rather than undergoing forced assimilation into this new culture and risk losing the critical faculty they once possessed, these cardiologists are simply refusing to be part of this new trend of cardiovascular fees and board certifications. Younger generations, who have growing families and have a less clear-cut future ahead of them, are less likely to take this “rogue-like” stance. Therefore, it seems that we need to ask ourselves 3 simple questions before taking any board examination.
1. Can I afford it right now? This is a real issue for most FITs. Most certification examinations cost approximately $1,000 (Table 1). Board review courses also cost about $1,000 (for online access, or more if traveling to the board review is required). Most fellowship programs do not cover these costs. Most FITs are also privy to the fact that board review organizers/speakers are also former writers of the examinations, further increasing the desire of test takers to take a board review course. Additionally, other review resources, such as online question banks and review textbooks, lead to additional costs. To give a real-life example, if an FIT were to undertake an advanced fellowship (e.g., electrophysiology), plus take all of the subspecialty certification examinations offered, then he or she would have to spend a whopping $15,000.
2. Am I taking this examination because I have to or because I want to? In my experience, most FITs take board examinations for 4 main reasons: 1) other FITs took the examination in previous years in their program; 2) their co-FITs are currently taking the examination (i.e., peer pressure or competition); 3) they want the prestige and/or credential that comes with the certification; and 4) for the educational benefit derived from preparing for the examination, because fellowship didactics cannot feasibly cover all the nuances of every subspecialty. Something most FITs do not realize is that some of the board certifications may be required by a future employer to obtain reading privileges. For instance, Certification Board of Nuclear Cardiology certification is commonly required to obtain reading privileges in certain hospitals. Interestingly, some attending physicians frequently argue that taking board examinations during fellowship detracts from an FIT’s research activities and clinical duties. Although it is easy to sign up for a board examination, passing the examination may not be so easy. For instance, the ASCeXAM pass rate in 2014 was 68% (Table 1). Passing that particular examination requires hours of reading and a level of understanding of echocardiography that is not attained from standard didactics and rotational knowledge gained during fellowship. Knowing pass rates can, therefore, help tailor one’s time and resources.
3. How will it benefit my career? Although some specialty boards are mandatory for practice (e.g., interventional), others are not. The latter fact should elicit a much more thoughtful decision on the part of the FIT or cardiologist before proceeding. For instance, if you want to start a hypertension clinic, then taking the American Society of Hypertension examination will be highly beneficial. As mentioned above, “do I need certification to obtain reading privileges?” I have heard stories of hospitals revoking reading privileges for more senior members of groups who did not recertify, leaving that group struggling to keep up productivity. Last, “will having the board certification make me more marketable when applying for jobs?” For instance, a cardiologist applying for a job in a rural area wanting to start a vascular program will be highly desirable if he or she has a Registered Physician in Vascular Interpretation certification.
When we, as FITs, examine the road ahead, there are 2 separate but parallel routes that can be traveled (Figure 1). Regardless of the path chosen, there will undoubtedly be a long road full of financial burdens. The future of cardiovascular diseases will likely be continued specializations, new board certification examinations (e.g., interventional echocardiography or cardiac magnetic resonance imaging), and fewer didactics for trainees. It is quite clear that the younger generation of trainees and cardiologists have been catapulted into a new, less-stable world of cardiovascular medicine. Other than reinventing fellowship tracks to reflect the more specialized nature of cardiology, I cannot think of any solutions to this surge in subspecialization certifications. And even this potential solution is also not ideal, as a certain foundation of knowledge is essential to be able to effectively care for cardiovascular patients on a day-to-day basis.
Taking some of the aforementioned specialty board examinations has certainly solidified my knowledge in those specialties, and this knowledge will certainly spill over to my future patients. However, I strongly encourage every FIT and cardiologist to make calculated decisions when deciding which, if any, of the subspecialty examinations they are going to take and how they are applicable to their future career pathway and skill set. In other words, we should be continually asking ourselves individually, “what type of cardiologist am I building?”
RESPONSE: Punching the Ticket
With the candor and passion we expect and value from our fellow-in-training colleagues, Dr. Maybrook has highlighted issues that are both important and timely. Before a few comments about them, I agree with his concluding emphasis on patient care, in the context of career focus, as the appropriate driving force for training choices. The career focus that my comments will directly address is clinical cardiology, including the additional competencies and certifications that many seek concurrently with the standard 3-year cardiovascular fellowship training.
Of the issues raised by Dr. Maybrook, perhaps most fundamental, given the range of available society certifications beyond the standard American Board of Internal Medicine (ABIM) cardiovascular disease certification, is the following question: just what is a clinical cardiologist, and should not most trainees be able to achieve the necessary knowledge and skills for this within the 6 graduate medical education years that include the standard cardiovascular disease fellowship and its certification process? For clinical cardiologists, the question often relates to the range of imaging and cardiovascular testing modalities and the desire of, and perceived pressure on, fellows to be able to “do it all.” “Punching the ticket” is a phrase I have occasionally overheard.
The most recent American College of Cardiology (ACC) COCATS (Core Cardiovascular Training Statement) 4 provides some help (1). It more clearly defines the specific competencies (and outcomes measures) expected of all clinical cardiologists, but it also includes mechanisms for additional individualized career-focused experiences and competencies within the standard fellowship. It also indicates competencies (or combinations of them) that cannot reasonably be obtained during the standard fellowship. Importantly, the statement places additional emphasis on direct patient care, including longitudinal care, along with the appropriate use and clinical integration of all of the things we do, not just the number of things that we individually can do. Implementation of this approach should not diminish the employment opportunities for our trainees, especially in the era of an evolving focus on population and value-based care. Recognizing the financial burdens of prolonged training and the ever-growing cardiovascular curriculum, the ACC, in conjunction with the ABIM, is also currently at 4 sites undertaking a pilot program that permits selected individuals to begin gaining cardiovascular competencies during the third year of internal medicine residency. Application of this paradigm could lead to additional time for career-focused training for these individuals during their standard 3-year fellowship period.
The issue of multiple professional society “board examinations” is complex. These societies are important parts of our profession, and each plays a key role in the development and evolution of very specific knowledge bases and skills. They have helped set standards for training and performance and have established criteria for advanced leadership and trainer roles in selected clinical areas. Discussions about alignment of these examinations are ongoing, including better distinction of imaging and testing competencies required for clinical cardiology practice from those required by selected individuals for advanced research, program leadership, and leading educational programs. Although the issues are not yet resolved, the ACC is engaged in discussions with the ABIM and other relevant bodies to address the issues and the associated costs and demands. At present, perhaps the best approach is that outlined in COCATS4—to align advanced training in selected areas with relevant areas of career focus for the individual trainee (1).
The cost of certification (and recertification) processes is difficult to understand, and is troubling. At the least, more transparency along with actions to control costs is required. In the area of recertification, no one can argue with the need for lifelong learning and assurance of maintenance of practitioners’ competency over time, but the degree to which this can be coupled with the physician’s own outcomes and performance measures in his or her practice should be a key component. The ACC is focused on developing tools to facilitate this—both from time and cost considerations—as well as to enhance personalized education. As we do every day in our training programs and on the wards, we will benefit from the candid and insightful input of the next generation of our profession.
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