Author + information
- ↵∗Address for correspondence:
Dr. Zain Ul Abideen Asad, Cardiology Fellow, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, AAT 5400, Oklahoma City, Oklahoma, 73104.
The traditional cardiology training pathway has entailed 3 years of internal medicine (IM) residency followed by 3 years of cardiology fellowship with optional additional training. The rationale behind 6 years of training in this traditional pathway has never been rigorously tested or clearly articulated. Concerns about the significant burden of student loans and the inordinate time it takes to train have been recognized (1). The need for an innovative competency-based training track in cardiology was recognized 2 decades ago by Fuster and Nash (2), but the efforts to introduce newer, nontraditional models for training have been few and far between. However, the American Board of Internal Medicine’s (ABIM’s) competency-based pilots have challenged the traditional structure of residency and fellowship training (3). In 2014, the ABIM’s competency-based pilot in IM and cardiology (Pilot) was started with 4 participating institutions (Icahn School of Medicine at Mount Sinai, Indiana University School of Medicine, University of Oklahoma College of Medicine, and Vanderbilt University School of Medicine), each supporting 1 Pilot resident/fellow each academic year (4). Incorporation of core competency requirements in graduate medical education and the publication of cardiovascular-specific milestones by the American College of Cardiology provided the necessary momentum for the Pilot (5).
At the core of the Pilot is the creation of a blended third year of IM residency with 4 unique cardiology experiences in echocardiography, vascular medicine, preventive cardiology, and stress testing (Figure 1). Pilot trainees are selected during their second year of IM residency, and the Pilot requires that IM residency and cardiology fellowship take place in the same institution. The total duration of IM and cardiology training remains unchanged in the Pilot at present; however, it does allow for early cardiology-focused training during the third year of IM residency while still preserving the core IM rotations. The 4 clinical rotations mentioned above, unlike electives during IM residency, fulfill ABIM requirements for both IM and cardiovascular board certification (Figure 1B).
Recently published preliminary results of the Pilot appear promising in both confirming the benefits of earlier cardiology-focused training and initiating discussions to potentially shorten the training required to become a practicing cardiologist (6). However, assessment of any nontraditional training pathway should include feedback from multiple stakeholders. Therefore, we present our perspectives and experiences as first-year (Z.A.) and second-year (C.T.) cardiology fellows enrolled in the Pilot.
The Application Process
Unlike the traditional cardiology fellowship, the application process for the Pilot started in the middle of the second year of IM residency. Similar to the standard cardiology fellowship application process, we were required to submit letters of recommendation and personal statements before a formal interview process.
There were unique aspects and challenges to the pilot application process. First, the accelerated application timeline, which was 6 to 8 months in advance of the National Residency Match Program application submission deadline, required an earlier commitment to cardiology fellowship. This also required earlier engagement in research activities and outreach for letters of recommendation. This accelerated pace did not pose significant difficulties for us, as our strong interest in cardiology had developed very early during IM residency. However, we realize that the process could be challenging for those who make fellowship training choices relatively late. Second, the Pilot’s structure required both IM residency and cardiology fellowship to take place within the same institution, precluding consideration of other fellowship programs. Because both of us wanted to enter the cardiovascular fellowship at our parent institution of IM residency, the Pilot was a good option for us and our families. We were also spared from the expensive hassles of traveling for interviews and taking time out of educational rotations.
The Pilot “Blended” IM year
Transition periods in training are stressful due to high expectations regarding knowledge, competencies, and decision-making skills. The Pilot allowed us to gradually assume a higher level of responsibility during the blended third year, which helped make the Resident-to-Fellow transition easier. Carefully structured rotations in the Pilot prepared us effectively for direct patient responsibility and honed our theoretical knowledge. These included:
1. Rotations involving interpretation of diagnostic studies without significant direct patient care responsibility (echocardiography and stress testing).
2. Rotations with heavy cardiovascular and IM crossover (vascular medicine and preventive cardiology) with direct patient management and clinical decision making.
During these rotations, our assignments were that of the first-year cardiology fellows, including reporting echocardiograms. Thereby, the Pilot was instrumental in facilitating a smoother and more confident transition for us to first-year fellowship.
At the start of the blended rotations, we were concerned about finding the right balance between being a third-year IM resident and a pilot resident/fellow. Some level of apprehension on our part regarding our readiness to assume clinical responsibilities closer to a fellow-level trainee rather than a resident was to be expected. These concerns, however, did not materialize. Our peers treated us no differently from other residents who were pursuing cardiology fellowships, and our faculty provided us significant supervised autonomy that the first-year fellows typically receive. The harmonious interaction between the IM and cardiology departments and intense faculty development regarding the goals and expectations of the Pilot were cornerstones to the success of the blended year, and will likely be critical in replicating the Pilot at other training sites.
One of the unique aspects of the ABIM Pilot is that IM and cardiovascular training are completed at the same institution. The opportunity to continue training at the same institution assuaged the emotional and financial stress that comes with moving to a different city and acclimating to the unique challenges of practicing medicine in a different academic health center. Additionally, the continuity of training in the same institution helped us to carry our ongoing research projects to completion.
The addition of 4 competency-based cardiology-specific rotations in the blended year resulted in a more rigorous but interesting and meaningful third year of IM residency. For us, this was a more efficient use of our training time, as it focused on our future career goals. The trade-off of completing cardiology-specific rotations during the blended year was giving up 4 IM elective rotations (e.g., endocrinology, rheumatology, pulmonology, gastroenterology, or other IM subspecialties). We do not feel that the unique structure of the blended year created any significant gaps in our core IM knowledge. Our participation in the IM continuity clinic remained unchanged during these 4 structured rotations, and at the end of IM training, we felt as capable as our peers in patient care. We were also able to prepare for the ABIM certification examination in IM as rigorously as our peers and passed the examination with good scores.
Beyond the Pilot Blended Year
During our first year of cardiology fellowship, we found the faculty eager to teach us relatively advanced concepts in echocardiography generally reserved for the second year of cardiology fellowship. We attribute this to the structured exposure and experience in echocardiography that we received during the blended Pilot year. Our attendings seemed to have relatively higher expectations from us compared with first-year fellows assigned to the traditional pathway. However, we observed that we were treated similar to traditional first-year fellows in other areas of cardiology not covered by the blended year, such as the cardiac catheterization laboratory.
Completing 4 months of cardiology-themed rotations during the blended year creates the opportunity for 4 additional elective months during our third year of cardiology fellowship. These rotations could be tailored to our areas of interest and have the potential to facilitate a more effective transition from fellowship to subspecialty training or clinical practice.
We hope that the Pilot findings would lead to a shorter training period to become a cardiology specialist. The trend of increasing length of training in cardiology subspecialties, such as electrophysiology and structural interventional cardiology, imposes a significant financial burden on current trainees. The current training duration of 8 years or more after medical school to become a subspecialist in cardiovascular disease is indeed daunting. Any new training pathway that offers a shorter duration of training without compromising the education or attainment of necessary competencies is certainly attractive to us and our peers.
The ABIM Pilot in IM-cardiology offers an opportunity for a long overdue paradigm shift in graduate medical education training of future cardiovascular specialists. The Pilot pathway offered us the attractive prospect of staying in the same institution for both IM residency and cardiology fellowship training while beginning the core training experiences in cardiology several months earlier (Table 1). Apart from the stress of preparing a competitive application much earlier than the traditional National Residency Match Program, our experience with this program has been overwhelmingly positive. We hope that the Pilot results would pave the way to reconsider the pathway to train cardiovascular specialists of the future. Reducing the total duration of training while still producing well-trained cardiologists should be our future goal (7).
We thank Dr. Chittur Sivaram for his guidance and critical review during the preparation of this manuscript.
- 2018 American College of Cardiology Foundation
- Doroghazi R.M.,
- Alpert J.S.
- ↵American Board of Internal Medicine. ABIM competency-based medical education pilot programs. Available at: http://www.abim.org/program-directors-administrators/competency-based-medical-education-pilot-programs.aspx. Accessed August 7, 2018.
- ↵American Board of Internal Medicine. ABIM internal medicine-cardiology pilot program. Available at: http://www.abim.org/program-directors-administrators/competency-based-medical-education-pilot-programs/internal-medicine-cardiology.aspx. Accessed August 7, 2018.
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