Author + information
- Harsh Golwala, MD∗ (, )
- Sadip Pant, MD and
- Prafull Raheja, MD
- ↵∗Reprint requests and correspondence:
Dr. Harsh Golwala, 550 South Jackson Street, ACB, 3rd Floor, Louisville, Kentucky 40202.
The adoption of healthier lifestyles, better strategies for risk stratification, and the advancement of medical therapies have led to the decline in incidence and prevalence of ischemic heart disease in the United States over the last decade (1). This, in turn, has led to a decline in the number of percutaneous coronary interventions (PCIs) performed in the United States (1). Multiple studies have demonstrated an approximately 15% to 20% reduction in PCI volume over the last decade. In contrast, noncoronary interventions such as endovascular interventions for peripheral arterial disease and, more recently, structural interventions for aortic and mitral valve diseases have shown an inclining trend over the past decade.
Duration of Training Conundrum
The transition from coronary to noncoronary and structural interventions has lengthened the training period of interventional cardiology fellowship from 1 to 2 years and, in some programs, up to 3 years. This has led many trainees to consider streamlining their interventional interests to either coronary and peripheral or coronary and structural interventions, which would allow them to complete the interventional training within a reasonable period of 2 years. Despite the compromise, it demands 8 to 9 years of rigorous clinical training from initiation of internal medicine residency to completion of interventional cardiology fellowship. The duration increases further if the trainee opts to pursue a chief residency position along the way. Several questions arise at this stage:
1. Is the training process so long that trainees could feel burned out by the time they are out in practice?
2. Should the training be shortened?
3. If so, how should the training tracks for interventional fellowship be designed?
The answers to these questions are clearly not simple. One of the recent initiatives by the American Board of Internal Medicine involves a combined internal medicine/general cardiology fellowship program of 5 years (2). Although this option sounds attractive for applicants who have already decided to pursue cardiology as their destination field, it may be unfair to the residents who are still in the decision-making process about their future interests. The other option that has gained attention would be to shorten the general cardiology fellowship to 2 years and generate a 2 + 2 track for interventional cardiology. With recent changes lengthening the electrophysiology fellowship program from a 3 + 1 track to a dedicated 2 years after the 3-year general cardiology fellowship (3 + 2), the latter option of a 2 + 2 track for interventional cardiology fellowship sounds challenging (3).
Robustness of Interventional Training
The other face of interventional cardiology revolves around the training itself. My interaction with fellows from various institutions has raised concerns about the robustness of the clinical training in interventions owing to declining PCI volumes. The Core Cardiovascular Training Statement II guidelines suggest a minimum requirement of 250 coronary interventions as a benchmark for graduation in interventional cardiology (4). In prior decades, fellows graduated comfortably with more than 300 to 350 PCIs, but the decline in PCI volume has made it difficult for interventional fellowship programs to maintain a volume sufficient enough to graduate the trainee with enough experience to independently perform these procedures. One of the solutions to this problem might be to allow interventional fellows sufficient autonomy in the second year of their training to behave as a junior attending, taking calls for urgent interventions independently. Some institutions in the United States have successfully embraced this approach over the last few years. Another option might be to reduce the number of fellowship spots to maintain sufficient volume to train robust fellows with high procedural experience. However, is decreasing the number of spots going to limit the ability to meet the needs of patients as new advances are made? The answers to these questions are once again difficult and require attention by the American College of Cardiology.
Job Opportunities After Training
Finally, there is considerable fluctuation in the job opportunities after the completion of training year by year. Recent data from the Society for Cardiovascular Angiography and Interventions demonstrates that an average interventionalist performs a median of 75 interventions (interquartile range: 38 to 127 interventions) annually (5). With low numbers of annual PCIs, the interventionalists spend an average of about 20% of their work time in the catheterization laboratory, whereas the remaining 80% is devoted to general cardiology practice, seeing inpatient consultations, and imaging. This may create a sense of dissatisfaction among some interventionalists who would prefer to stay in the catheterization laboratory the majority of the time after having trained in the field for such an extended period. Furthermore, in the recent era, structural interventions like transcatheter aortic valve replacement and percutaneous mitral valve repair have emerged as a “hot commodity” in the market among fellow trainees. With a limited pool of patients eligible for such therapies, the question arises of whether training in structural interventions would yield satisfactory job opportunities in the real world. This is important, as structural procedures are currently performed mainly in higher academic programs or major private hospitals with cardiac surgery backup, and job opportunities at such places are clearly highly in demand in this day and age.
Several important issues revolve among fellows while deciding on an interventional cardiology career. The pursuit of streamlining the interventional training duration/positions without diminishing its robustness as well as balancing it with future patient care needs requires input from all major cardiovascular professional societies. It is an exciting time of rapid advances in the era of percutaneous therapies available, but the time is now to consider how to best train and adequately address future public health needs.
- Deepak L. Bhatt, MD, MPH ()
RESPONSE: What Is the Optimal Duration of Advanced Physician Training?
The authors raise several important, complex, and inter-related issues regarding the hot topic of optimal “DAPT” (in this case, duration of advanced physician training). I commend them for honestly discussing key concerns that our professional societies and leaders have raised before and will continue to re-examine (1–3). The first has to do with the cumulative length of internal medicine training, followed by general and subspecialty cardiovascular fellowships (1). There is no question that this has evolved into a very long period of time. Practical consequences from the trainee’s perspective may include delayed income-earning potential, postponement of starting a family, and “training fatigue.” As a profession, we must acknowledge that these are valid concerns. However, it is important to examine the issue from the perspective of the patient and of the public at large. Neither particularly cares about the issue of training duration. Patients want a physician who is well trained. With the increasing body of medical knowledge that has accumulated, there is likely a longer period of time that is necessary to master it. Work-hour restrictions during medical training may have unintentionally worsened the problem by shortening physician trainee exposure to direct patient care and decision making.
Of course, patients also want a caring, empathetic physician, and a burned-out trainee entering practice would not be desirable. I am not convinced, though, that the majority of fellows entering practice are burned out—of course, on a busy call night in year 8 of training, I realize they may feel that way! Therefore, I do not think that there is an imperative to reduce the length of training for the potential benefit of increasing trainee satisfaction versus the potential risk of detracting from their ability to provide top-notch clinical care. In fact, the authors themselves state that case volumes in interventional cardiology are insufficient at an increasing number of training programs—shortening training will not help with that real issue. Mine may be an unpopular view among some physicians in training, but our first priority must be patient-centered and doing what is best for patient care and safety.
The second critical issue the authors raise really has to do with workforce prediction. As the saying goes, prediction is difficult, especially about the future! Indeed, predictions about oversupply and undersupply of physicians have been notoriously inaccurate. Expanded primary care and subspecialty roles of physician assistants and nurse practitioners (whose length of training is increasing, by the way) could drastically alter physician workforce needs and composition. The next wave of extreme cholesterol reduction may significantly decrease cardiovascular event rates, and the necessity for cardiologists may greatly diminish. Or, new interventions for heart failure and valvular heart disease may escalate demand (4,5). These and other uncertainties increase the value of broad training—in internal medicine and in cardiology—even if a trainee is planning to be a sub-subspecialist. As the authors point out, the majority of designated interventional cardiologists (at least in the United States) practice a fair amount of general cardiology. So, again, I come to the conclusion that adequate duration and diversity of training are beneficial, providing some insurance against obsolescence to the physician facing an unclear future cardiovascular landscape. In this circumstance, there will not be a large randomized trial to define optimal DAPT, and we will be left with expert consensus. Assuredly, from those experts, there will be an element of “back in the days of giants when I was a house officer” that every generation of physician trainees has to suffer listening through; yet, undoubtedly, there is also a substantial degree of wisdom that only comes with experience. Thus, from the perspectives of the patient and also the individual physician, adequate training—and the substantial sacrifices it surely entails—remain essential to the transformation from trainee to attending physician.
I would like to thank Kevin M. Alexander, MD, a cardiovascular medicine fellow at Brigham and Women’s Hospital, for his thoughtful review of my response.
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- ↵American Board of Internal Medicine. Clinical cardiac electrophysiology policies. Available at: http://www.abim.org/certification/policies/imss/ccep.aspx. Accessed May 24, 2015.
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