HF Specialists Detail ‘Road Map’ for Improving HF Training Pipeline

Amid mounting concerns over the dwindling pipeline of physicians choosing heart failure as a subspecialty as the patient population explodes, prominent heart failure leaders have published a “road map” for “reinvigorating” training pathways to entice more physicians to the field.

As previously reported by TCTMD, more than half of the advanced heart failure and transplant cardiology (AHFTC) fellowship positions in the US went unfilled in 2022, leading a growing chorus of voices to call for a new approach.  

But as the perspective published Wednesday in the Journal of Cardiac Failure (JCF) points out, the suboptimal interest in this fellowship, just 10 years after its creation, is starkly at odds with the “remarkable” gains being made in the field. “With over 6 million patients living with HF in the United States alone, the umbrella of therapeutic options for these patients now includes a wider range of options than ever before, rendering a palpable sense of energy and excitement in our field,” write Vanessa Blumer, MD (Cleveland Clinic, OH) and colleagues.

“There was so much attention, as evidenced by that Twitter thread, as to why so many fellowship spots were left unfilled in heart failure,” Anu Lala, MD (Icahn School of Medicine at Mount Sinai, New York, NY), senior author of the paper and deputy editor of JCF, told TCTMD. “I think it's very important for us to get the right messages through, which is not that, oh my God, nobody wants to go into heart failure, but really: can we understand as a community why this is the case and really be more data-driven about it?”

Getting that data will be key to “bridge the divide,” Lala continued, “between the dearth of fellowship applicants and the fact that there are so many therapeutic advances in this field that are so exciting, and the fact that we have this incredible need for a larger heart failure workforce given how many millions of Americans are living with heart failure.”

That information, as the road map authors propose, should come in large part from a series of surveys targeting fellows in both general cardiovascular disease and AHFTC fellowship programs, the directors of those same programs, and, lastly, current heart failure cardiologists.

According to Blumer, the Heart Failure Society of America (HFSA) already has assembled a task force to address the pipeline shortfalls, with the understanding that survey data will be “crucial to better understand the underpinnings of the problem. While I don’t know the exact time line,” she told TCTMD in an email, “I know that HFSA has established this a top priority, so I am hopeful that as a community we can work towards important changes this year.”

Tackling Training Updates

With those responses in hand, said Lala, a number of additional steps can be taken, as specified in today’s perspective.

For one, training within the AHFTC fellowships could be revised to allow for specialized training “to acquire skill sets in other domains beyond heart transplantation and LVAD.” Such specialization could include:

• A general heart failure track focused on optimizing and implementing guideline-directed medical care and “more nuanced management of specific cardiomyopathies (infiltrative, inflammatory, genetic)”
• A critical care/interventional HF track incorporating more in-depth training in cardiogenic shock, temporary mechanical circulatory support, interventional cardiology, and ICU care
• “Specialized HF” that would encompass adjacent fields such as cardio-obstetrics and cardio-oncology, as well as the myriad conditions that overlap with HF with preserved ejection fraction

The cardiovascular disease fellowship, as noted by TCTMD last month, also deserves a rethink, argue Blumer et al. On the one hand, exposure to AHFTC within the general cardiology fellowship should be standardized across programs to ensure that trainees appreciate the breadth of opportunities. On the other hand, more flexibility within general fellowships would permit more-personalized education pathways.

“Depending on the background, skills, and career goals of individual trainees, elective time may be devoted to additional HF training and this added exposure could enable some trainees to gain an added level of competence, render more-specialized HF care, and/or gain skill sets to perform or interpret certain HF-relevant procedures,” Blumer et al propose.

To TCTMD, Lala acknowledged that revising the general CVD fellowship “requires a coordinated effort in advocacy across the professional societies” as well as “educational bodies” such the Accreditation Council for Graduate Medical Education, the American College of Cardiology’s Core Cardiovascular Training Statement, and the American Board of Internal Medicine. That collaborative process would need to acknowledge what’s feasible across sites to allow for programs that may not provide certain types of specialized care, she noted.

The right messages . . . is not that, oh my God, nobody wants to go into heart failure, but really: can we understand as a community why this is the case and really be more data-driven about it? Anu Lala

But most would agree that revisiting the heart failure content provided in the general cardiology training pathway is long overdue.

“Cardiovascular medicine as a field has changed dramatically and it continues to change,” Lala said. “Maybe I'm biased because I am a very proud heart failure physician, but I would argue that all subspecialty fields within cardiovascular medicine intersect at heart failure and what may have been deemed an appropriate amount of time exposed to the heart failure subspecialty [in the past] likely now no longer applies.”

Blumer agreed: “The first step is recognizing that it’s time for a change, and the time to work towards that change is now.”

Compensation and Quality of Life

Of the proposed solutions to the pipeline problem tackled in the perspective, the toughest is likely their calls to improve compensation for heart failure specialists. “Compensation models based on relative value unit (RVU) productivity do not consistently favor HF cardiologists, who routinely spend larger portions of time in the evaluation and management services (E/M) and care coordination, compared to other cardiovascular subspecialties.” Revisiting this approach, particularly given the “downstream” revenues typically reaped as a result of optimal HF care upstream, justify a shift to value-based payment models, they argue.

“I recognize that compensation can be a dissuading factor for some trainees, and remain hopeful that a future in HF will explore compensation models that fairly match the specialized care we are providing,” Blumer said. “Personally I believe this is all outweighed by the daily reward and privilege of providing care for HF patients and being part of this community.”

The first step, stressed Lala, is getting the data to make informed changes. “And the data starts with surveying all of the relevant stakeholders in this problem,” she said. “What are the deterrents of going into heart failure training? There has been a lot of speculation: oh, it's driven by compensation, it's driven by the necessary extra time required, it’s driven by the paucity of jobs, it's driven by the fact that people are not adequately exposed to heart failure during general fellowship. . . . . While all of those may be true and playing a role, we need to understand what are the primary drivers, what are the primary deterrents, and then be solution-oriented based on the answers to those questions.”