Conversations in Cardiology: Time for an Interventional Fellowship Match?
Morton Kern, MD, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in cardiology.
Morton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.
Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), asks:
Just wanted to see if others have been feeling that this year’s interventional fellowship application cycle is crazier than ever?
With many programs on ERAS now and Zoom interviews, there are several issues:
- Some programs still take applications directly (outside of ERAS)
- For those that do use ERAS, applicants essentially getting applications together after a single year of fellowship
- Programs having to review applications and offer interviews in literally a few days/week of when it opens
- Interviews pushed to the earliest point we’ve ever seen (mid-December) and applicants having multiple Zoom interviews all within 2 weeks of ERAS opening for programs
- Programs giving applicants exploding offers, with responses in some cases required on the spot or within 24 hours
- Multiple applicants pulling out of interviews because of #4 and #5
It has always felt like a free-for-all, but this year seems to have taken the cake. Are others feeling the same? And why do we not have a fellowship match?
Kern:
My response: We take principally from internal candidates only unless no one wants to stay. Interviews are in person, but we already know the fellows. We've considered taking from only outside, but it doesn't make sense to us as we use this process to strengthen our general fellow applicant pool.
We should have a fellow match just like other specialties.
Let's see what the big programs think.
James McCabe, MD (UW Medicine, Seattle, WA):
It was a crazy calendar race this year—really bad. Five of the 10 applicants we offered interview spots dropped out within 3 days before the interview, because they had offers in the first week following ERAS and had to decide within 24 hours. I think we, like everyone else, feel increasing pressure to move our interview day earlier and earlier to deal with this. There’s got to be a better way.
Gurpreet S. Sandhu, MD, PhD (Mayo Clinic, Rochester, MN):
This is a very timely discussion. 2021 has been an incredibly unusual interview season. We always interview all of our internal candidates and also have a diverse selection of external candidates that are also interviewed. The rankings are done independently by each member of our interview panel, then tabulated by our education coordinator upon conclusion of all interviews.
The interviews were impacted firstly by an inability to bring external candidates on-site due to the pandemic, so external fellows had no opportunity to see the facilities or have in-depth interactions with faculty, current fellows, and other cath lab personnel.
Additionally, it appears that many centers were making offers to candidates that they had to accept or reject on the spot, and this type of pressure is a great disservice to individuals who are going to be our future colleagues.
It would be very reasonable to think about leveling the playing field for all candidates and institutions by having a standardized match, with the usual flexibility for spouses/partners.
Douglas Drachman, MD (Massachusetts General Hospital, Boston):
I am so grateful that you brought up this important topic. We definitely use ERAS, and this year has been the craziest that we have ever seen, although there has been insidious creep over the past 10 years.
Historically, we prided ourselves on hosting a single day of interviews where every faculty member interviewed every top candidate and we introduced the candidates to our current fellows. We felt that this enabled the candidates to get a great sense of our program, opportunities for mentorship, and a sense of the quality of life for fellows. Also, the faculty were able to get to know each of the candidates, and to consider ways that we might optimize their experience in the incoming class. This recruitment day used to take place in April . . . then March . . . then January. Last year, we filled our program with internal candidates so have not experienced the “recruitment rush” for 2 years.
As Ajay described, this entire process has accelerated dramatically, probably enabled by the ubiquitous use of Zoom interviews, instead of in-person. Although we had planned to review ERAS applications on the weekend of December 11 and consider a strategy for interviews as a team some reasonable time thereafter, we learned quickly that candidates were receiving “exploding” offers from other institutions and were reaching out to learn about our dates. We have done our best to accelerate the process and accommodate.
I’m concerned that this process ultimately favors the programs that are most aggressive (and nimble) to review applications quickly, contact fellows, and recruit immediately. It does not allow the candidates to take time to get to know the various programs, consider what is best for them, and—importantly—to coordinate other aspects of their lives (professional/personal needs of a partner, family, geography, and so on).
As a society, we need to create a more fair process that puts the fellows first. This is the way that the general cardiology match has worked; electrophysiology and heart failure have followed suit. I believe strongly that the interventional-fellowship recruitment process should be governed by a match. This can only work if all programs participate fairly in this process.
Frederic S. Resnic, MD (Lahey Hospital & Medical Center, Burlington, MA):
Thanks so much for this discussion. I need to admit that I am not the one running the fellowship selection process. But from my perspective, I do think a match would actually be fairer to the applicants and also reduce the inevitable slide to earlier and earlier interviews for every program. I understand that having a match requires the programs to give up a bit of control over the process, but it seems to be more efficient for our other programs (general cardiology and electrophysiology).
Larry S. Dean, MD (UW Medicine):
Starting to remind me of times past when there was no process!
Barry Uretsky, MD (UAMS Medical Center, Little Rock, AR):
I completely agree with Ajay and others. A better selection method is needed. I strongly favor a match. At this point, interventional cardiology is an outlier in that regard.
We completed our entire process on December 19. We feel, like many programs, we are forced to start early to get good candidates.
So I do think it's time to strongly encourage a match. I think the support of big programs would be helpful in this regard.
Bonnie Weiner, MD (Saint Vincent Hospital, Worcester, MA):
I generally agree with all the comments so far. I think most programs tend to “keep their own” for a variety of reasons. The major one being they are known quantities with known skills and experiences. There is definitely something to be said for that. Programs that want to continue to do that, and if there is a match, then need to not list the total number of positions but only list those they are willing to fill with outside applicants. Programs also need to commit to not filling listed positions outside the match. That has been one of the barriers to getting consensus on a match.
Fellows from smaller programs like ours are already somewhat disadvantaged if they want to explore opportunities outside our training but have generally been successful, albeit with needing to apply to more programs. Despite them being excellent cardiologists and well-trained angiographers, they frequently are not asked for interviews. I don’t know that a match would change that, but hopefully it would not make it worse.
In general, though, I think a match is a good idea for everyone as long as the playing field and rules are clear.
Kern:
One of my fellows said this morning that he interviewed with a Milwaukee program and afterward they immediately offered a position with an immediate request for a yes/no acceptance. He asked me what he should do. I said it sounds like a forced sale and consider his options. He called back, and they said they'd give him 2 hours to consider the answer.
Very unsettling and a bad precedent, especially for smaller programs.
Weiner:
My fellows have had similar experiences.
Michael Ragosta, MD (UVA Health, Charlottesville, VA):
This was a major problem for us last year, and I’m sure it’s worse this year (we took an internal candidate this year).
Last year, seven individuals accepted our invite to interview by Zoom; they were offered an interview and accepted the interview on the same day.
Within 24 hours of accepting the invite, three dropped out because they accepted another position elsewhere. We quickly set up Zoom interviews for the remaining four.
Two were offered positions from other institutions before we completed interviews, and they felt that they had to accept since we were not yet ready to make an offer.
We finished at 6 PM and, after a brief discussion with our group, offered a position to one of them and fortunately got lucky and got an excellent fellow.
This all transpired over about 48 hours.
It’s not fair to the fellows who are coerced into taking a position that might not be best for them but worried about not getting a position. It’s not fair to the programs who have to make split decisions about fellows without having time to check references or even complete a proper interview process. The reliance on Zoom that evolved from the pandemic has allowed this craziness to happen.
I am all for a match in interventional cardiology.
Neal Kleiman, MD (Houston Methodist Hospital, TX):
I’m not certain that I see this as such a tremendous problem. Things have been more frenetic this year due to the ease with which applicants can interview remotely without having to commit to travel. On the other hand, they can see many more programs than they would with face-to-face interviews. They may be pressured to make decisions quickly (we give applicants 24 hours), but in truth there are also deadlines when they rank programs for the match. On our part, it usually requires several phone calls to secure a candidate, and sometimes a little horse trading, which I would bet ends up being a lot less time commitment than dealing with match-related paperwork.
My major concern about matching is that for those of us who are trying to get creative with our programs, a match algorithm may not fit the bill. Currently, we take one internal and one external applicant. As we go to 2 years, with the second year super-subspecialized, that is going to make for some interesting combinatorial mathematics that I don’t think the match can fulfill. We’ve had to grind our teeth a lot this year, but I’m convinced that the applicants and programs will largely enter January knowing who’ll be going where.
James Blankenship, MD (University of New Mexico, Albuquerque):
One other unfortunate consequence of the current system occurs when a cardiology fellow accepts the interventional position, then gets a “better” offer and bails on his/her initial commitment. That happened at my institution several years ago. The result is a lot of confusion and unnecessary angst while the urgent search is undertaken for the replacement.
A match seems like a no-brainer as a better way of doing it.
John Hirshfeld Jr, MD (Penn Medicine, Philadelphia, PA):
This problem is at least 90 years old.
When my father was a 4th year student at Cornell, he was on a trip to interview for residency at Case Western Reserve, which at the time he believed to be his first choice. While on the train from Cleveland back to New York, Yale placed a phone call to his apartment offering him a residency position with a requirement to accept immediately. His roommate, who answered the call, made the snap decision to accept on behalf of my dad and, as a result, he did his surgical residency at Yale, where he met my mom.
So from my standpoint it was a good thing.
Theodore Bass, MD (UF Health, Jacksonville, FL):
I do, as most of you, agree that a match seems reasonable for fairness and transparency when it comes down to graduate medical education. I have had a son that has gone thru this process as a “consumer.” My sense is from an applicant’s standpoint other important issues need to be considered, most notably the time, travel, and cost expense to apply to multiple programs potentially often involving an invited mandatory visit. I am not sure regarding the future of Zoom visits once the COVID situation is controlled. I hope they continue, although they are less than optimal, especially for the applicant. Many of these advanced-training applicants have families, responsibilities, and a significant amount of debt once they reach this stage of interventional cardiology training.
It would be interesting to know if a match system increases or decreases the number of applications, interviews, and associated travel costs per applicant. I can make an argument for either effect.
Does anyone have any data on this? I do think it is a very important consideration we often overlook.
Paul S. Teirstein, MD (Scripps Clinic, La Jolla, CA):
Really good points, Ted. We do like to see our applicants, and pre-COVID we were very careful only to interview about five for three spots. If we have a match, I suspect we will need to interview around 20. It might make it a bit harder on the applicants.
Stephen Ramee, MD (Ochsner Medical Center, New Orleans, LA):
We ask our applicants to reply within a reasonable amount of time. I have heard of programs that demand an answer immediately. I disagree with that practice and think it should be condemned.
Kleiman:
We give 24 to 48 hours. Most fellows have stratified their choices by the time they interview; we’ve never had one that needed longer. The problem is that if you give lots of time to applicants in series, you could easily spend 3 weeks in limbo if your first few calls are to individuals who aren’t decisive.
Kenneth Rosenfield, MD (Massachusetts General Hospital):
Match is LONG overdue. How should it get started?
Kern:
I suggest the Society for Cardiovascular Angiography and Interventions (SCAI) leadership meet with the ACGME matching committee and set the rules for the interventional fellowship applicants. The discussion here would also provide background on our perceived current state of affairs and inform the SCAI/ACGME working group of our concerns and needs.
Kirtane:
I would be in full support of that, Mort.
David Cox, MD (Brookwood Baptist Health, Birmingham, AL):
I agree fully with your great idea about SCAI pushing this with ACGME . . . . But you know and I know, best-laid plans . . . .
I think the only way this works is for SCAI to push at the presidential level so Tim Henry, present el jefe (ie, President), and Sunil Rao, upcoming in May 2022, are going to need to help us make the right contacts to make rain happen with ACGME for a match to become reality and not a dream. Both are on this email chain.
I always admired and respected Kirk Garratt’s ability to work the back channel with any organization SCAI needed to reach out to. He paved the road when too often I followed him and got the credit.
Tim and Sunil, I’ll leave it to you two to work the magic like Kirk did, but I’m worried this will get buried in committee/amongst staff if you don’t have a firm hand and drive the discussion with ACGME forward on a personal and forthright level. It will take both of you coordinating the drive to take this hill.
SCAI President Timothy Henry (The Christ Hospital, Cincinnati, OH), and SCAI President-Elect Sunil Rao (Duke University Medical Center, Durham, NC):
Based on discussions at the SCAI Fellows meeting in Miami and this conversation, the SCAI Executive Committee has formed an “Interventional Cardiology Match Task Force” to outline steps required, including discussions with ACGME to establish an interventional cardiology match.
The National Resident Matching Program (NRMP) describes on its website how best to begin:
“How Many Programs Do We Need to Start a Match?
Because Matches are more successful when the majority of programs participate, NRMP has developed criteria that encourage greater success. Each Fellowship Match sponsor must verify annually that:
- at least 75% of the programs with available positions for the appointment year will be registered for the Match,
- those programs will actively participate by submitting rank order lists, and
- at least 75% of the available positions within the specialty will be registered with the NRMP.
Fellowship Matches occur throughout the year and Match schedules are developed in coordination with the sponsor to best suit the needs of program directors and applicants. There is no cost to sponsoring organizations and minimal fees for programs and applicants.”
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