Author + information
- Zaher Fanari, MD∗ ( and )
- Sandra A. Weiss, MD
- ↵∗Reprint requests and correspondence:
Dr. Zaher Fanari, Section of Cardiology, Christiana Care Health System, 4755 Ogletown-Stanton Road, Newark, Delaware 19718.
Cardiovascular diseases are still considered the leading cause of death in the United States (1). It is estimated that 40% of Americans will experience some form of cardiovascular disease by 2030 (2). The advances in cardiovascular care required to meet this increased demand depend on the continuous involvement of fellows-in-training and early-career physicians in research and quality clinical care—in both the academic and private sector. However, the pursuit of a purely academic career is jeopardized by many obstacles, including prolonged training periods, expanding debt burdens, increasing discrepancies between academic and private practice salaries, difficulty regarding visa requirements for international medical graduates, and significant limitations of government funding for research (3). Quality clinical care in the private setting is also potentially compromised by physician burnout induced by the increasing cost of malpractice insurance, billing issues, increased documentation requirements, reimbursement and financial considerations, and challenges of work/life balance (4,5).
As a result, choosing a post-fellowship career between academic or private practice cardiology is quite challenging, especially given the changing environment in either pathway. The increased costs of malpractice insurance and the implications of the Patient Protection and Affordable Care Act, along with decreased reimbursement and increased documentation, has led to considerable insecurity in the private job sectors. Thus, there have been significant changes in the demographics of the cardiologist job market, with a move from a 90% independent private practice pattern in 2007 to approximately 50% hospital-employed cardiologists over the last 7 years (5). This change has presented many new roles for clinical cardiologists, including involvement with administration in varied provider settings, as well as quality improvement processes and even a limited or expanded research component. Furthermore, the expansion of graduate medical education toward involving many private community hospitals added an educator responsibility for many previously strict clinical private cardiologists, whether they were prepared for that or not (5).
Furthermore, a closer look at those defined as academic physicians shows that they are not as homogenous a group as one would think. A recent survey performed by the American College of Cardiology (ACC) estimated that 7% to 10% of those identified as early-career cardiologists are academic cardiologists (6). Of these, 40% were identified as either clinical-educators (25%) or clinical-educator-administrators (15%), with very limited research involvement (6). The remaining 60% were involved in research to varied degrees (1% with 100% research commitment, 8% at >75% research, 13% at 40% to 75% research, and 38% at <40% research). As in the private sector, this survey indicated the many obstacles for those committed to research, including lack of time (78%) and unstable funding from limited and highly competitive external grants (National Institutes of Health [NIH] or NIH equivalent), as well as financial disincentives to research from lower clinical relative value unit (RVU) tracking (73%), burdensome regulatory compliance (72%), overemphasis on RVU- based metrics of performance (62%), and insufficient support from the home institution (52%) (6). The need for academic cardiologists to achieve a higher volume of clinical RVU tracking with less involvement in research and the shift in the job description of many private cardiologists to include different degrees of administrative, education, and research endeavors has made the border between academic and nonacademic career pathways less defined.
Many challenges that early-career cardiologists face—regardless of their pathway—can be tracked back to a lack of sufficient training and career planning early on in fellowship. For example, the top 4 reasons cited by the NIH for grant failure (inadequate preparedness or commitment to research, poorly designed career development plan, poorly developed research proposal, and lack of mentorship) seem to be related to a profound level of inadequate training and dearth of appropriate mentors in fellowship. Fellows pursuing academic careers need enhanced training in proposal writing and proficiency in specialized research skills (e.g., basic, clinical, and translational research techniques). Both often require committed mentoring as well as additional schooling for advanced degrees (e.g., MPH or MSc) with additional, often expensive educational costs and time (3,6). Similarly, challenges faced by educators and administrators are related to the absence of appropriate training to acquire needed education, administration, and leadership skills, respectively, during fellowship. Compared with researchers and educators/administrators, clinical cardiologists are likely best exposed to their field of expertise during fellowship training. However, even this is becoming challenging. Fellows are increasingly overwhelmed trying to acquire high-quality, effective clinical skills in catheterization, electrophysiology, and/or imaging, especially with the continuous advances of the cardiac tools required by all subspecialties. All the while, fellows are attempting to dedicate more time and effort to achieve better competency in research, education, and administration during the current 3 years of fellowship, albeit to various extents and variable quality.
For fellows to be prepared for the challenges awaiting them, the ACC has suggested many solutions, with an emphasis on improving the quality of fellowship training (6). Regardless of which pathway fellows choose to pursue, training should be directed toward delivering cost-effective clinical care with an emphasis on quality improvement. Fellowship also needs to move from a concept of procedure count to a universal concept of competency, efficiency, and quality of skills acquired during training. Involving fellows in quality and safety projects early is crucial to develop the skills required to provide a higher-quality care down the line. Mentorship is an essential part of training, and providing sufficient time and credit for successful mentors is vital to sustain this process. Fellowship programs should provide at least a minimum baseline education on the basics of research, education, and administration for all fellows. With the help of an active mentorship process, more emphasis and comprehensive training and skills development beyond the basics on each of these aspects can be supplied for those who are interested in pursuing a more defined pathway. For example, those who are interested in a research career can be trained and mentored early with more dedication to grant writing and epidemiology and with emphasis on skills pertinent to manage grant failure. Leadership training for those interested in administrative roles can be achieved within fellowship or on the national level by encouraging national cardiology leaders, including department chairs, program directors, and other division leaders, to educate fellows on the details of their specific supervisory functions and the skills required to excel. For an alternate pathway toward education, training in education with emphasis on curriculum development, educational assessment, and accreditation regulations, as well as training in educational methodology and mentorship, is critical.
The changes in the practice pattern in the cardiology field in the last few years and the associated changes in the roles that cardiologists are expected to play after fellowship have been dramatic and have made career planning more complicated. Cardiology fellowship programs, with the help of the ACC and the other leaders, have to adjust with these changes and be prepared to provide the fellows with the appropriate training on many levels that can enable them to excel in their prospective careers. Active mentorship programs and appropriate incentives can offer the resources needed for successful career transition from fellowship to early cardiology career.
RESPONSE: Cardiology Fellows’ Dilemma of Academic Versus Private Practice: Is it the Wrong Question?
If you ask cardiology fellows who are beginning training what they want to do, they frequently say a combination of patient care, teaching, and investigative work. It is a nice answer, and they might mean it, but it is far from reality for most. During a sabbatical in South Africa, I asked cardiology fellows what they wanted to do. Most expressed interest in teaching and research (almost all done in the public sector), but none of them intended to actually do that. The earnings for 1 month in private practice exceeded the earnings for 1 year in academic medicine. Fortunately, it is not that out of balance in many parts of the world, and in recent years, the earning potential is now not dramatically different between private practice and academic choices. One reason is that academic medical centers have taken on care delivery with such vigor that they act much more like private practices. Private practices, on the other hand, have morphed into an employment model with more clinical research (primarily funded by industry). Thus, for the small percentage of cardiology fellows who end up in careers devoted more than 75% to academic endeavors, the challenge is to be committed from an early stage—often before fellowship—and to have well-connected mentors who can enable grant writing success. For the vast majority of fellows who enter clinical or academic practice, the opportunities for clinical research will fall to those who commit to it, develop superior investigational methods, and devote countless hours to drive projects, often at the expense of missing out on clinical RVUs. Institutions that want to be in the forefront of clinical research should find ways to reward those who pursue these nonreimbursable activities, but you cannot fully buy the commitment to research and teaching that primarily comes from the innate desire of the young trainee. The rewards that come from the treatment of appreciative patients are great and sufficient for many, but others will find the challenge of teaching and clinical investigation necessary as well. Training in cardiology should be pursued with an understanding of oneself, so as to prepare for the career that will be most rewarding. As the new COCATS recommendations aim for competence-based training, fellows should master those basic competencies while also preparing for the career they envision. In this rapidly evolving health care environment, my advice is to pursue training for the kind of practice desired without excessive concern as to whether it is initially structured within an academic or private practice environment.
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