Author + information
- Georges Ephrem, MD, MSc∗ ()
- Department of Cardiovascular Disease, Hofstra–North Shore–LIJ School of Medicine at North Shore–LIJ Health System, Manhasset, New York
- ↵∗Reprint requests and correspondence:
Dr. Georges Ephrem, Department of Cardiovascular Disease, North Shore–LIJ Health System, 300 Community Drive, Manhasset, New York 11030.
Medical training stands prominent among the most demanding career choices. Whether in intensity or duration, it requires a tremendous amount of commitment, along with a willingness to endure the financial burden of medical school loans. For the bold candidates who accept the challenge, the angle resides in the early years of practice when the higher income would allow them to pay off their debt as well as start their lives. However, the trend over the years has been toward a decrease in income and reimbursement and an increase in the years of training. Nowhere is this truer than in the field of cardiology.
Cardiologists have noticed a steady decline in their income over the years, such as the 8% decrease in median income between 2012 and 2013 per a nationwide survey data from 134 cardiology programs representing 2,554 cardiologists collected by MedAxiom (Neptune Beach, Florida), a consulting firm that specializes in cardiology practice management (1). This finding suggests that the start of their careers promises to be more arduous than for previous generations of cardiologists, with quality of life jeopardized by the burden of their loans, independent of the other expenses of life (housing, transportation) and/or families (cost of living, education). This is happening in a context of extended training.
Over the years, whether by design or by the pressure of competition, cardiology fellows-in-training (FITs) have found themselves pursuing additional specialization regardless of career inclination (2). In electrophysiology, the standard has been for 2 years of training, with some programs offering a third year dedicated to research. Very few institutions offer a 4-year “fast track,” which uses the third year of general fellowship with a concentration on electrophysiology as an unofficial first year of subspecialty. Understandably, this option tends to be available solely to the fellows who are completing their general cardiology training at these specific institutions. In interventional cardiology, although the American College of Graduate Medical Education (ACGME) solely recognizes 1 year of subspecialty training, the vast majority of programs have moved to a 2-year commitment, adding a non-ACGME–accredited second year dedicated to additional structural training, peripheral interventional training, or research. For noninterventional tracks, especially academic ones, many FITs are opting for at least 1 additional year of training in advanced imaging. The rationale is to achieve level 3 in Core Cardiology Training Statement milestones in nuclear cardiology and/or echocardiography, or to secure board eligibility in cardiac computed tomography and/or cardiac magnetic resonance imaging (3). Others are opting for an extra year of vascular training to achieve board eligibility in vascular medicine. This additional training is not exclusive to the academic setting. “Private” practices today prefer noninvasive cardiologists who have vascular certification or who are credentialed to interpret vascular studies (“RPVI certified”). Even niches, such as intensive care cardiology, are now being considered for a structured 1-year fellowship by the ACGME, despite ample exposure during general fellowship. As for the novel career paths, advanced heart failure and transplant cardiology requires 1 additional year of training, whereas adult congenital heart disease now mandates a 2-year fellowship.
If we consider an average age of graduation from high school of 18 years, 4 years of undergraduate studies with pre-medical requirements, 4 years of medical school, 3 years of residency, and 3 years of general cardiology fellowship, we find 32-year-old individuals with sizable student loans pending, looking at more years of training. This is a hypothetical “best-case scenario” as the reality is far more complex. Due to the fierce competition for entry to medical schools, students often resort to 1 to 2 years of research to improve their curriculum vitae. More medical schools now offer or encourage their students to spend an extra year between their third and fourth years conducting research or joining projects abroad for similar purposes. In 2014, according to the National Resident Matching Program, the match rate in cardiology was around 70% (4). To prepare a solid portfolio, medicine residents try to work in research in parallel with their residency responsibilities. Oftentimes, they opt for an extra 1 to 2 years as a post-doctoral fellow or accept the position of chief medical resident, a dedicated fourth year in internal medicine. If we then account for the fact that the average age at medical school matriculation is now 24 years (5), we easily can realize that overall FITs are close to 40 years of age by the end of general cardiology training. After these years of training, pending loans and financial pressure from growing personal responsibilities have many FITs forgoing further training regardless of their preference.
The spectrum of activities that cardiologists perform has broadened tremendously, requiring more specialized training than before, the later years of which are the most critical. In addition, there is less tolerance for and more scrutiny around errors, which entails that the trainees “hit the ground running” immediately after fellowship. In an age of permanent connectivity when patients have access to all available published data online, the expectation is for the FITs to remain up to date as well. We believe that this knowledge can be acquired without the need to invest as many years in training. As suggested in prior reports, there are various levels at which actions can be taken for this purpose (6). At the medical school level, one can advocate for a 5- or 6-year program starting after high school or to at least combine the first 2 years of the current model into one. Medicine residents going for fellowship could be exempted from completing the third year. The same applies for general cardiology fellowship and subspecializing trainees. This would give FITs 3 to 4 years of their lives back. It would also encourage those interested in advanced training paths to pursue their dreams without being excessively penalized for it.
At the career day of the 2012 Scientific Sessions meeting in Los Angeles, the then-American Heart Association’s president Dr. Mariell Jessup congratulated FITs on “embarking on a career of lifelong learning.” We echo Dr. Jessup’s words and confirm our enthusiasm for our beloved chosen profession. We are, however, worried that we are looking at a career of lifelong training. Preserving and furthering our medical knowledge is a necessity that could also be fulfilled through targeted intensive courses, maintenance of certification, evidence-based reading, and various conferences and seminars. This might be the proper juncture to explore new avenues. One century after the Flexner report (7), it is time for us to intelligently and responsibly revise the structure of medical school programs and adapt them to our day and age. At a time where the American Board of Internal Medicine, the American Board of Medical Specialties, and the ACGME are modifying their certifications and welcoming novel specialties, we owe it to the future FITs to support them in their career choices by caring for their well-being and supporting their paths as lifelong learners.
- Alfred A. Bove, MD, PhD ()
RESPONSE: Lifelong Training
Is the End in Sight?
Dr. Ephrem elucidates a growing dilemma among cardiology trainees in this second decade of the 21st century. In years past, cardiology fellowship provided enough training and skill for the cardiologist to function in the echocardiography, catheterization, and nuclear laboratories and to see patients and provide general cardiology care in the ambulatory setting. Critical care was a given, as the critical care unit was an ongoing training ground where fellows rotated frequently in their 3-year program. In this century, echocardiography has progressed from 2-dimensional and m-mode to 2-dimensional, transesophageal, intracardiac, and intraoperative. The skills required to interpret 2-dimensional echocardiography have become more complex, procedures became part of the education, and eventually, the specialty of multimodality imaging has evolved into a quasi-specialty. In the catheterization laboratory, diagnostic catheterization gave way to interventional catheterization, first with balloon angioplasty, then percutaneous coronary intervention, and then structural intervention. The required skills went beyond what could be acquired in a 3-year general cardiology fellowship almost to the point where interventional cardiology has now become a surgery-like specialty with multiyear training needed after cardiology fellowship. In most instances, these advanced skills have led to the scrub suit cardiologist who performs procedures throughout the day with little time to provide outpatient care for patients with chronic heart disease. We have discovered that unique knowledge and skills are needed to manage end-stage heart failure, ventricular assist devices, and heart transplant patients, as well as adults with complex congenital heart disease. Each of these needs has led to specialized training, additional fellowship years, and board certification. Electrophysiology, now well delineated from general cardiology, is expanding to a 2-year post-fellowship training program.
As Dr. Ephrem points out, many cardiology trainees will be older than 40 years of age with considerable debt when they finally enter the world as an employed cardiologist. For female cardiologists, this can mean a significant delay for childbearing, and taking a maternity leave during fellowship often leads to extended fellowship time to make up for missed training time. Our world of superspecialization seems to be relentlessly moving ahead. Much of this trend is driven by hospital systems seeking cardiologists with enough skills to justify income by procedural billing. From a health system perspective, seeing patients in an outpatient office setting is the least profitable use of a cardiologists’ time, so there continues to be the pressure for more procedural skills to justify the cost of the integrated cardiology practices.
Can we reverse this cycle? It might be possible by putting more value on the care of patients rather than the number of procedures a cardiologist performs. Coming soon are the changes dictated by the Medicare Access and CHIP Reauthorization Act of 2015 that was signed into law in April 2015. If implemented as planned, physicians will be rewarded by substantial bonuses for quality and outcome-based measures, not procedural volume. A merit-based Incentive Payment System is planned that will score physician performance on a scale of 1 to 100 on the basis of practice measures, not on volume. Such systems will recognize the value of the clinical cardiologist and are likely to lower incentives for more specialized skills. It will take several years to change the reimbursement system, but the goal is to morph into a value-based payment program by 2022.
Thus, there is a chance that in 6 or 7 years, the incentives for more and more superspecialization will be reversed, and the clinical cardiologist will be recognized with higher value, diminishing the demand for procedural skills. Overall expenditures on health care are likely to fall under this system, which suggests that cardiology salaries are likely to fall as well. Although all of this looks good in theory, the actual changes are very unpredictable, and are likely be compromised by political pressure to maintain the present procedure-based reimbursement system. Given the uncertainties, fellowship is likely to continue to be divided into superspecialties into the near future. Although it is tempting to become a narrowly focused proceduralist, we risk losing the care of our cardiology patients to the primary care physicians if we do not commit to providing long-term care for our patients.
- 2015 American College of Cardiology Foundation
- ↵MedAxiom. Physician compensation and production survey. Available at: http://www.medaxiom.com/clientuploads/PDFs/PhysCompProdSurvey_r8.pdf. Accessed December 12, 2014.
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- ↵National Resident Matching Program. Results and data: specialties matching service. Available at: http://www.nrmp.org/wp-content/uploads/ COCATS-3-Recommendations-for-Training-in-Adult-Cardiovascular-Medicine-Core-Cardiology-Training-Revision-of-the-2002-COCATS-Training-Statement 2013/08/National-Resident-Matching-Program-NRMP-Results-and-Data-SMS-2014-Final.pdf. Accessed September 14, 2014.
- Flexner A.