For cardiology fellows, drive to subspecialization is intense

Fellows discuss how technology, information are pushing them to choose a subspecialty.

Members of the Cardiology Today Fellows Advisory Board met recently to discuss the changes they expect in cardiology over the next several years. The wide-ranging discussion moderated by Chief Medical Editor Carl J. Pepine, MD, also considered the strength of current cardiology training programs and changes that are needed. Send your comments about this discussion to editor@cardiologytoday.com.

Moderator
Carl J. Pepine, MD Eminent Scholar, Professor and Chief, Division of Cardiovascular Medicine, University of Florida, Gainesville, and Chief Medical Editor of Cardiology Today.
Reena Pande, MD Fellow in Cardiovascular Medicine, Brigham and Women’s Hospital, Boston.	Uday N. Kumar, MD Cardiovascular Innovation Fellow, Biodesign Program, Stanford University, San Francisco.
Thomas Cabell, MD Fellow, Division of Cardiovascular Medicine, University of Florida Health Sciences Center, Gainesville.	Ty J. Gluckman, MD Physician, Providence St. Vincent Medical Center, Providence St. Vincent Heart and Vascular Institute, Portland, Oregon. Former fellow at Johns Hopkins, Baltimore.
Roderick Tung, MD Fellow in Cardiovascular Medicine, Cedars-Sinai Medical Center, Los Angeles.

CARL J. PEPINE, MD: How do you see the field of cardiology changing during your career?

REENA PANDE, MD: I see the focus being more on subspecialization. Fellows feel pressed to pick a subspecialty to focus on as they move forward. It’s challenging for those who want to be general cardiologists.

TY J. GLUCKMAN, MD: The field of cardiology used to be one where you could have an expansive skill set. Now you are forced to subspecialize and pick an area that you really feel you can master.

PEPINE: When do you think candidates are making these choices — during their first year or second year of training?

GLUCKMAN: There are some candidates who seem to have known from birth what they wanted to do and they have followed that route. A lot of candidates, myself included, came in very open and weren’t sure. Certainly by the end of their first year and into their second year they begin to develop an idea and can narrow down that field. It’s not always so easy to do from the very beginning. The curriculum during your first year is often quite varied and exposes you to lots of different things.

RODERICK TUNG, MD: I agree with that. We often follow a technological imperative of whatever is available. I went into cardiology not wanting to be a radiologist, but now there are going to be radiologists of the heart.

UDAY N. KUMAR, MD: There definitely is a big focus on subspecialization because of advances in technology and the increase in the volume of information for each subspecialized area of cardiology. Additionally, even if fellows want to do general cardiology, they feel that they need to be able to do something outside of just the patient-physician interaction, something that generates income because so many are finishing much later in life, have two spouses working, and have large loans to pay back.

THOMAS CABELL, MD: Trainees also feel the added stress to be good at all the modalities. I think program directors wrestle with that daily in trying to expose people to enough intervention and enough noninvasive and enough imaging and enough clinical exposure so that three or four years from now the fellow will be confident to take on these challenges.

I’m overwhelmed by the amount of data and the amount of technology that’s available to us that we don’t really get exposed to in our training. It’s a big challenge for programs to coordinate these things and will eventually require somewhat of a paradigm shift from the way training is approached.

Right now, training requires three years of medicine and three years of cardiology and an extra one or two or three for research and/or imaging and/or interventional or electrophysiology. Sometimes it may take eight or nine years for people to finish their training.

KUMAR: While there may be increased subspecialization, this trend could place a greater emphasis on disease processes. To take care of a particular disease process, such as heart failure, you may have to have skills from different parts of cardiology or you may have to work with a group of colleagues that together have all of the skills necessary to take care of all aspects of the disease process.

GLUCKMAN: I’m being trained at an academic institution that is trying to turn out academicians. The perspective as a trainee coming through an academic program is somewhat skewed in the sense that an academic program gears you for a career that fits within the schema of an academic institution. The way we’re being trained is in a model that works very well within an academic environment, but it may not necessarily be so applicable if the trainee’s ultimate goal is to be a great cardiologist in the community.

PEPINE: I’ve always thought that we ought to have two types of cardiology fellowships. We ought to have one like you have at Johns Hopkins, and we ought to have a community-based program. For people not wanting to go into academic medicine, training them at our academic centers is not necessarily the best exposure. For people who want to pursue academic careers or at least be affiliated with an academic program, an academic training program would be better.

PANDE: Role modeling is also important. If you come out of a program like Mass General or Hopkins, for example, the only people you see around you are people who are highly specialized. I think you’re pushed to be like the people you see around you.

PEPINE: We had a Bethesda task force conference on workforce issues about two years ago. Our conclusion was that we need more cardiologists and that we need to figure out ways to shorten the training program, at least the general training program.

One working group proposed that we shorten the general cardiology training program by one year. The idea was that the third year of internal medicine residency would merge with the first year of cardiology fellowship into a year in cardiovascular prevention. We said that person ought to remain in the medicine residency program, but it would be a mixed-cardiology first-year fellow and then you would move on to your second and third year and to more subspecialization.

The ABIM initially was very favorable, but they studied it last summer at their retreat and came back in the fall with: ‘We like this, but we’re not in the mode of doing things only for one of the 12 subspecialties that we certify. And so, if we do it for cardiovascular disease, it’s got to be for everybody.’

ABIM had all 12 subspecialty boards look at the proposal and apparently only five or so were interested. So, it looks like that idea is in limbo. What is your reaction to a plan in which we would try to merge the third year of medicine residency with the first year?

CABELL: My feeling has always been that two years of medicine was enough if you were at a program that was fairly labor intensive with a lot of in-house call, if you got a lot of exposure and didn’t do a lot of outpatient clinic work, and if you knew you were going to subspecialize.

PEPINE: The task force said that the principles you would learn would be common to whatever you went into. It didn’t make any difference what data set you used. Of course we were looking at it with rose-colored glasses, but we think that this could not hurt the third-year resident even if the resident changed their mind. If this curriculum were appropriately structured, it would be targeted at almost all the subspecialties.

The criticism among the task force was concern about the candidate who then says, ‘I really am into this and I want to go a little bit more in depth.’ Is that candidate going to be ideally suited to go into, for example, an EP training program or some other very detailed subspecialty? And I guess the simple answer to that is probably no.

CABELL: But you would be gaining an extra year to subspecialize, whereas now there may be only an extra year of interventional or EP. You could have an extra year to subspecialize, to do a two-year interventional fellowship, for example.

GLUCKMAN: I think the other issue is a fellow’s expectation of what they’re going to get out of fellowship. In years past it was reasonable to design a curriculum if they were interested in being a clinician within a three-year period to allow them to be certified at advanced levels of readership, maybe not to run labs but to read different imaging modalities, do different procedures. As the procedures have become more complex, the number of procedures has increased, and the individual areas have become more complex. The perspective of fellows going through training today has got to change.

The reality is that there is a lot of information out there that you need to know. As the field and potentially CMS begin to link reimbursement to a certain level of either board certification or a certain basic level of requirements, it’s going to get to a point where you have to master a certain area before we give you compensation for certain procedures. There’s a disconnect between fellows thinking it’s unfair, yet at the same time we want all of these things.

PEPINE: My vision has been that the fellow is presented with a menu and you make selections. You have to make choices. You can’t cover all the bases. Now, that’s immensely unpopular when you talk to the fellows about it, but I think that’s the way we’re going.

Thomas Cabell, MD

CABELL: There is an enormous amount of information and a fixed time limit. Either you keep adding on months and years to cover it all, or you just pick and choose off the menu what you want.

PEPINE: What is missing from your training programs?

CABELL: The business aspects of medicine and cardiology in particular.

PEPINE: You mean business practices, efficiencies, so that you can get the maximum out of the time that you put in and also see the most patients?

KUMAR: Yes, with pay for performance this will be very important. If you really are doing the right thing you want to get credit for it.

GLUCKMAN: The majority of cardiologists in the United States are not coming from academic institutions. We need to know what their lives are like as cardiologists.

PEPINE: That’s a good point. Fellows could do a month rotation in some varied aspects of cardiology that are not academically based. You could shadow somebody in either the device or the drug industry. There is probably a comparable exposure in government or at the FDA.

PANDE: Women are also missing from our training programs.

PEPINE: Why is that? I have three daughters; two of them are physicians and one is a nonphysician in a medically related field. Medical school classes are pretty close to parity in terms of women and men.

Ty J. Gluckman, MD

GLUCKMAN: I think the length of training certainly impacts the decision for a woman to go into cardiology. For women that I know who are in medicine in their late 20s and want to start thinking about having a family, going into a cardiology training program may take three, four, five, years, depending upon what they want to do.

PEPINE: Perhaps we should have a more relaxed track that would allow a woman during her child-bearing and child-rearing years to get trained and to work, but not necessarily with a 20-hour day.

PANDE: Fifty percent of medical students are women, even more than 50%. About 30% to 35% of internal medicine residents probably are women and only about 15% to 17% of cardiology fellows. We are putting together a survey of our house staff and hope to understand what the issues are.

I certainly have my own beliefs, which have to do with family and the lack of role models and a perception of the inability to combine one’s professional and family life, which may or may not be true depending on where you are. I’m married to a cardiology fellow and I have a 2½-year-old child. I was pregnant when I applied for a fellowship, and I started my fellowship with a 10-month-old. It has worked out very well for me.

Other women need to see that there are people like that out there who can make it happen. It may not require a relaxed program, but it may require a program that understands that people have needs outside of the hospital.

KUMAR: We also need to build in some flexibility among our co-fellows. Some people don’t take time off when they should, and if someone gets sick or someone gets pregnant, there are people who complain that they now have to cover the cath lab for another month. Those attitudes need to change.

PANDE: I think the more people that actually do it and the more women and men who are able to balance work and family, the more understanding there will be.

GLUCKMAN: Formal mentoring programs also seem to be missing in a lot of training programs. We all need an advocate who will take a personal interest in our future. We also need an advocate who can help us with our career decisions.

TUNG: Most of the time we’re forced to find an eclectic mixture. You can’t find one person that is just your overall mentor. There’s one person that wants your deadlines to be filled and there’s another person that really cares whether you’re actually happy as a person.

KUMAR: I think junior faculty, since they’ve gone through it just recently, are often more your friend and can lend a little transparency to the process, letting you know whether something is a reasonable salary offer. People who have just recently gone through it sometimes are more open to seeing you not make mistakes they made by giving you some tidbits of advice.