Fellowships in Advanced Interventional and Structural Cardiology Need Structure, Planning, and Collaboration—Stat!

2016-2017 Fellow Talk Bloggers                                                                                                                                                                                                                              

Call us gluttons for punishment or overachievers, but interventional cardiology fellows in the United States—myself included—have been increasingly signing up for an additional year of training beyond the traditional 1-year coronary interventional fellowship. This trend has been propelled by an increasing number of structural and endovascular interventions being performed nationally, fueled largely by tremendous strides in technology and improved outcomes in clinical trials. In addition, fellows also feel the need to learn more skills prior to starting independent practice in a highly competitive job market, particularly for those interested in academic careers. 

There are currently 25 advanced interventional and structural programs listed on the American College of Cardiology (ACC) website—the only database resource currently available to fellows who are interested in pursuing a second year of interventional training in the United States and Canada. Yet, because the Accreditation Council for Graduate Medical Education (ACGME) does not accredit advanced programs (I recently published a paper on this exact topic in Catheterization and Cardiovascular Interventions), there is no uniform curriculum for these advanced fellowship programs to follow. Because of issues like these and more, as advanced fellows, it is upon us to initiate a collaborative effort and start communicating with one another about the structure of our respective advanced fellowship training years, sources of funding that enable hospitals to support our training, the types and the number of procedures in which we participate, autonomy levels, and expectations from advanced fellows who have completed their advanced training. 

Here are five key steps that should be taken by fellows and those involved in training us to facilitate streamlining of advanced interventional and structural cardiology fellowship programs nationwide.

1. Determine the number of advanced fellows

Talking with interventional fellows across the country, there seem to be more advanced interventional and structural cardiology fellows (in their eighth year of postgraduate training) than suggested by the ACC website. For example, the interventional fellowship programs at the Hospital of the University of Pennsylvania, Cleveland Clinic, and Brigham and Women’s Hospital are 2 years long and train interested fellows in structural heart interventions without them having to apply separately. None of these programs are listed on the ACC website. Deciphering the accurate number of advanced interventional and structural cardiology fellows is not only important to establish a metric, but also for foreseeing whether the right amount of interventionalists are being trained to meet the needs of our ageing population with complex comorbidities. This knowledge will also be helpful for strengthening the case for accreditation of advanced interventional and structural cardiology by the ACGME.

2. Establish a consistent curriculum

In 2010, the Society for Cardiovascular Angiography and Interventions (SCAI) established a structural heart disease council and published a paper that discussed the kind of procedures that encompass the domain of structural heart interventions. Right now, individual programs teach advanced and structural interventions with no guidance from an accrediting organization. But to further facilitate the streamlining of training for our successors, it will be important to standardize learning and determine an optimal minimum number of cases for them to meet in order to graduate.

3. Do not ignore coronary interventions

Unlike our mentors, who were established coronary operators when they were first introduced to advanced interventional and structural heart procedures, interventional fellows today have just concluded their first year of training and have evolving skill sets that require continued practice. In an ideal setting, coronary interventional exposure should be part of the advanced fellowship curriculum, allowing more experienced fellows to scrub on coronary cases, although with the recognition that first-year interventional fellows have priority.

4. Emphasize cardiovascular imaging

Knowing about my interest in structural heart interventions ahead of time, I planned to obtain Core Cardiovascular Training Statement (COCATS) Level II training and board certification in adult comprehensive echocardiography as well as COCATS Level II training in cardiac CT during my general cardiovascular disease fellowship. However, continued exposure and training in cardiovascular imaging is vital for development of any advanced structural interventionist. All second-year training programs should offer this invaluable exposure to their fellows. New programs especially can learn from established ones and inculcate rotations in cardiovascular imaging as part of their curriculum.

5. Strike a balance between training, research, and networking

Finding the time for fellows to balance all necessary components of their training—operating, outpatient hours, administrative duties, and dedicated research hours—is not unique to advanced interventional, or even cardiology, programs. However, in such a dynamic field, it will be necessary for program directors to pay even closer attention to the demands on their fellows’ time. Additionally, fellows should be permitted to travel for conferences and other academic symposia, and be able to seek sources of funding for their advanced year of training.

Establishing a comprehensive, nationwide repository of these programs with all of the aforementioned information will not only be quintessential for future interventional cardiologists, but also be the foundation for curriculum development and a resource for improving the quality of our training. Like we use the Heart Team approach for the most complex cases, it is time again to make a collaborative effort among fellows and faculty to optimally train the next generation of interventionalists.