A Changing Job Market for Fellows Requires New Perspective, Resources From Trainers

As the field of interventional cardiology continues to expand beyond the coronary realm and into endovascular and structural procedures, how is it possible for fellows to adequately prepare? And how can program directors adapt to a job market shifting from smaller, private-practice–based employers to larger health system models? But most importantly, how can fellows best be taught to differentiate between a practical, marketable skill and merely the latest trendy technique?

Fellows in interventional cardiology and those involved with their training must grapple with all of these questions and more.

In recent video interviews, several fellows told TCTMD that the biggest challenge today is finding a job. After all, “it is the first time in their careers where it's not automatic what [they] have to do next,” said J. Dawn Abbott, MD, of the Warren Alpert Medical School of Brown University (Providence, RI), who related that she has trained at least 20 interventional cardiology fellows in her 5-year tenure as program director.

Moreover, it has become more difficult for fellows to find jobs that they are really satisfied with, she told TCTMD in a telephone interview, adding that she has noticed a general increase in the amount of time fellows spend in training. “At least a quarter of my fellows—and sometimes half—do a second year.”

While adding another year to a training program already 4 times the length of the average American’s college career might seem superfluous to some, taking the extra time to potentially become more marketable is worth the opportunity cost for others. But Dr. Abbott noted that fellows might also be purely interested in acquiring extra skills because certain fields, like structural and peripheral, have been gaining momentum.

A ‘Renaissance’

In a telephone interview with TCTMD, Ehtisham Mahmud, MD, of the University of California, San Diego (La Jolla, CA), said that his experience as a program director—training at least 30 interventional fellows over the past 15 years—has enabled him to observe several fundamental changes in the field from a different perspective. He referred to the current era as “sort of a renaissance for interventional cardiology.”

Before 2000, debates raging among interventionalists had to do with proper GPI administration—abciximab was only approved in 1997—and lesion-specific stent selection. By 1999, 84.2% of PCIs involved stenting, though the DES era was still several years away. Procedures like TAVR and mitral valve repair were far from becoming reality.

When the initial interventional cardiology certificate examination was offered by the American Board of Internal Medicine (ABIM) in 1999, trainees focused the vast majority of their efforts on coronary skills.

“The field itself is no longer just coronary interventions,” Dr. Mahmud said. “One year… is a good way to get basic coronary interventional training, but then a second year [will enable] people to become peripheral interventionalists, structural interventionalists, or complex coronary interventionalists.”

That being said, “everybody can't do everything,” he stressed. “We need to get our fellows to better understand that.”

Dr. Abbott echoed this sentiment. “It would be really hard for most programs in the United States to get fellows sufficient numbers [of cases] to become competent [in structural skills] within a year,” she said. “Coronary alone is fine. Coronary and endovascular is often feasible at an intro level. But adding structural makes it more complicated…. The technical expertise will still lie within busier centers, at least over the next decade for structural.”

As opposed to Brown University’s program, which requires a second competitive application for its second-year advanced fellowship, other institutions that require fellows to stay for 2 years “are taking a more global approach to training,” Dr. Abbott continued. However, even after this type of training, “most individuals cannot maintain expert skills [in] structural and endovascular and coronary [procedures],” she said.

The issue, Dr. Mahmud observed, is that fellows “are getting exposed to it all—they're meeting the bare minimum requirements to do it all, and so they want to do it all. And they see mentors at their institutions who are doing it all, and then they think, ‘Well, I can do this.’” Yet according to Dr. Mahmud, when fellows transition into the job market, they may find it financially impractical to “do it all.”

“In private practice, nobody wants you to do a 5-hour case,” he explained. “Or you might end up in an environment when you have 2 cath labs and 25 doctors fighting for the slots.”

Dr. Mahmud said training environments often differ from actual practice. “We in the training programs do not do a good job of preparing them for the real world,” he noted.

“Real world” refers specifically to community hospitals, he explained, as these are where most fellows initially place after completing their training. As such, trainers “need to modify our approach and… keep it a little more focused,” he said.

Choosing the Right Amount of Training

Given the only recent influx of excitement about the structural field, Dr. Abbott said some of her fellows are worried that training in these skills will limit their job options “because it's not clear what the need is for those types of operators yet.”

Yet endovascular is “completely opposite,” she noted. “Right now, the fellows who train in endovascular are the most highly sought after because everyone sees it as an area of growth, and I think most hospitals can accommodate the resources needed for that in their cath lab.”

Yet good coronary operators remain valuable, Dr. Abbott said. “It’s still a breed of interventionalists that we need, and I think they have a lot of flexibility still. They can concentrate on complex PCIs and chronic total occlusions, or they can find their own niche within intervention that makes them very marketable. I don't think [it should be] mandatory to do all this training.”

Regardless of whether fellows seek extra training, Daniel M. Kolansky, MD, of the Hospital of the University of Pennsylvania (Philadelphia, PA), told TCTMD in a telephone interview that “it's a real plus for fellows and trainees that they will be able to take some of the things that just a few years ago were very restricted and very experimental approaches and now really apply them across the country.”

Another issue fellows have to consider is that whatever job they take after fellowship will likely be associated with a “substantial” proportion of noninterventional work, according to Dr. Mahmud. Though the pioneers of the field spent the vast majority of their time in the cath lab, maintaining a high procedural volume can now be a challenge for some fellows. According to NCDR data, the average coronary operator performs about 70 procedures annually, but certain outliers can log at least 250 or higher.

“Volume depends on location, hospital volume, referral patterns, expertise, and other factors. All interventional cardiologists spend time outside the cath lab,” Dr. Abbott said, adding that the average operator spends about 2 or 3 days per week in the cath lab. “Other time is spent in the office seeing consults and following patients longitudinally.”

Dr. Mahmud added, “It is almost impossible for a junior person to start as a full-time interventionalist without gaining additional experience. It is not perfect and they don't like the idea, but it is often how they have to start out.”

While some of these other duties require additional training—for example reading various noninvasive imaging modalities—they can provide early career practitioners with more variety in their jobs and “are generally reimbursed well,” Dr. Abbott commented.

SCAI Lends New Resources

Advancing the field to the next step will require resources that Drs. Abbott, Kolansky, and Mahmud all agree have been long needed. Each has worked with the Society for Cardiovascular Angiography and Interventions (SCAI) for the past few years to launch the Fellows in Training (FIT) portal last July. The portal is the “home base” for fellows and program directors, according to Dr. Kolansky, and features a core education component with 7 up-to-date lecture modules aligned with Accreditation Council for Graduate Medical Education (ACGME) requirements for certification, as well as career development resources, a job bank, and a procedure log.

Dr. Mahmud said he hopes to include research grant opportunities soon. Also, fellows registered with the FIT portal will have access to free registration for all meetings sponsored or co-sponsored by SCAI.

“If we want to ultimately impact the field and make it more scientific, more rigorous, and less criticized by society, government, and third-payers [about doing treatments] that patients don't need, then we need to work on making our fellows very well prepared—not just technically but scientifically and cognitively,” he said.

According to Dr. Abbott, “one thing that we as an interventional society don't do a terrific job at is advertising really well what programs are available for fellows. There's not just one single source.” If enough people use the FIT portal, she said, the chaotic, word-of-mouth-based process of applying should cease to exist.

Challenges Aplenty

The biggest challenge for future fellows will be to stay abreast of new technologies, Dr. Kolansky said. Program directors, he added, will need “to continue to provide the critical core curriculum that's needed for the standard activities in the field… as well as to provide enough dedicated training in the newer structural heart disease interventions.”

Funding for advanced interventional fellowships must also be obtained, Dr. Abbott noted, because they are currently funded directly through institutions or private donors. ABIM accreditation is one way for the programs to potentially receive Medicare and other government funding, but that would be accompanied by more oversight and higher expectations, she added.

Setting up new, specific boards—like structural or endovascular interventional cardiology—with the ABIM and ACGME could take undue effort, according to Dr. Mahmud. He supports adopting the model currently in place for cardiothoracic surgeons: “They have a basic training requirement, but every cardiothoracic surgeon doesn't do heart transplant, lung transplant, bypass surgery, and valve replacement. There has to be some self-regulation at the level of individual institutions, societies, and our overall groups.”

The ever-changing complexity of job structures is also something those involved with training will need to be highly attuned to, Dr. Kolansky emphasized. A 2009ACC survey reported a shortage of 1,941 interventional cardiologists. Yet another ACC survey showed that only 24% of job openings were in the clinical interventional field in 2013.

Even though jobs may be harder to come by, the overall system seems to be changing for the better. Dr. Mahmud explained that more fellows now are being hired into large health systems with guaranteed salaries and transparent job responsibilities. “The positive I see is that people are less apt to get hoodwinked,” he said. “They are doing less practice building and more being hired to do what they are trained to do.”

And even though Dr. Abbott said she has had to make more calls and write more emails on behalf of her fellows than she used to, she has not had a fellow go without a job.

“I do think it's going to continue to be an incredibly exciting field,” Dr. Kolansky concluded. “We should not lose track of that despite the pressures of the job market or finances or other issues.”