‘Ridiculous’ System Has Many Calling for an Interventional Cardiology Match

On a Saturday morning in December 2019, Issa Kutkut, MD, then a second-year cardiology fellow at Virginia Commonwealth University, sat in a Boston hotel room grappling with his biggest career decision to date.

The day before he had interviewed for a position as an interventional cardiology (IC) fellow at his home institution and then flown to Boston for another interview, set to occur after the weekend. He woke up to receive an offer from the first, but there was a catch—he had to accept within 48 hours, and in doing so forgo any future opportunities.

“I accepted it and then I canceled the Boston interview that was on Monday, very short notice, and I also had interviews down the road, which I canceled as well,” he told TCTMD. “When I got more interviews, I told them that I already got a position.”

The whole experience was “tough, unpredictable, and chaotic,” added Kutkut, who now works at Lutheran Hospital (Fort Wayne, IN).

Last December, Kiersten Frenchu, MD (Temple Hospital, Philadelphia, PA), then a second-year general cardiology fellow, told TCTMD she started receiving interview requests—virtual because of the COVID-19 pandemic—“almost immediately” following the opening of the Electronic Residency Application Service (ERAS) cycle on the first of the month. This was much sooner than even her co-fellows who went through the process the year before had warned her about.

“I had probably close to a dozen scheduled in the first two and a half weeks of December,” she recalled. “And then by mid-December, I had actually signed a contract for fellowship and was juggling multiple offers from all over the country. Obviously, part of this acceleration is from the virtual interviews. So COVID was, in a way, a blessing for the taking away the travel and the huge financial burden of traveling everywhere, but really rapidly increased the pace of the interview process.”

This ultimately made the process “stressful” for Frenchu. “It was really hard just to time manage all of the interviews because sometimes it was multiple on the same day,” she said. “And then the stress of getting offers, how exciting that was, was quickly diminished by how quickly they needed a ‘yes’ or ‘no’ answer. ‘Will you join them at XYZ location?’ There was never that much time to talk with your mentors or even your family, most importantly, about that decision.”

The stress of getting offers, how exciting that was, was quickly diminished by how quickly they needed a ‘yes’ or ‘no’ answer. Kiersten Frenchu

For their internal medicine residency and general cardiology fellowship beforehand, interventional cardiology applicants have participated in the National Resident Matching Program (NRMP) to match them to their programs after interviewing and submitting rank lists. And while all other cardiovascular specialty fellowships accredited by the Accreditation Council for Graduate Medical Education (ACGME) use a match system to place candidates,  interventional cardiology is the lone exception.

Not surprisingly, then, every trainee or recent graduate interviewed for this article had anxiety-ridden stories about their experience getting into interventional cardiology.

Sabeeda Kadavath, MD (St. Bernards Healthcare, Jonesboro, AR), recalled accepting her position with “still a dozen places left to interview at.” She reached out to these programs to let them know she was no longer seeking a spot, but they would still send her emails and even call her current program director to set interview dates, exacerbating any lingering doubts she had about having had to make a swift decision while demonstrating that even the programs themselves are paying a price. “There's no real tally in real time of who's accepted and who's not,” she said, noting that this adds up to a lot of wasted effort.

Saraschandra Vallabhajosyula, MD (Wake Forest University School of Medicine, Winston-Salem, NC), told TCTMD that when he went through the IC fellowship application process in late 2018 he received “a lot” of these so-called “exploding offers,” wherein he was expected to give an answer within 24-72 hours. “I went through the match for every single other landmark of my life except intervention, and this was by far the worst experience of my life in terms of how much stress and anxiety it caused,” he said.

Focusing on his work as a general cardiology trainee was practically impossible through this time, Vallabhajosyula added. “Thankfully for me, I was on an easy rotation and my program was able to give me time off, but I know many fellows who didn't have that luxury.”

A Process Accelerated

The ERAS website currently lists 177 interventional cardiology fellowship programs, including 12 that don’t participate and 19 that are unregistered in the organization’s annual application process, meaning that they accept applications independently. The ERAS application process as it stands allows candidates to begin their application before the end of their first year of general cardiology fellowship, with the applications released to programs for review in early December.

“We've seen this evolution occur over the past 10 years—and it's really accelerated over the past 2 or 3—where we used to interview cardiology fellows in the midst of their second year of fellowship,” Douglas Drachman, MD (Massachusetts General Hospital, Boston), told TCTMD. “It would often be sometime in April and that would be a little over a year before they'd be starting as an interventional fellow. . . . And it just very gradually moved from April or May to March then February then January. Just before the pandemic, there were a lot of folks who started receiving some offers earlier, primarily from their home institutions, calling and saying, ‘What could you do?’”

Last year, Drachman said his program received “around 160 to 180” applications for four spots, and within a week—before his team even had the chance to carefully review them all—“I had so many emails and voice mails from fellowship candidates saying we already have offers. . . . I just had never heard of anything like that before. It totally caught us unawares.”

I went through the match for every single other landmark of my life except intervention, and this was by far the worst experience of my life in terms of how much stress and anxiety it caused. Saraschandra Vallabhajosyula

J. Dawn Abbott, MD (Brown University, Providence, RI), who served as the program director for her institution’s IC fellowship up until last year, recalled a similar story. The current system is “way too rushed, where because there's no set time line for fellows, they had to sort of grab any opportunity presented to them,” she said. “They may have had interviews scheduled but they're put under ultimatums, which are really unfair to the applicant.”

The way the application process has evolved also “disadvantages individuals who come from programs without an interventional fellowship, who don't have the luxury of just staying where they are,” Abbott added. “It might also disadvantage some minority or underrepresented candidates who are really looking for a program that they feel can train them well and the environment is supportive. And from a program's standpoint, you lose the opportunity to showcase your strengths and to really sift through thoroughly the applicant pool.”

Drachman said the way the system has evolved has shifted “the power or the decision-making opportunity [from] the hands of the candidate, to rather favor the programs.”

When he applied for IC fellowship in 2019, Wally Omar, MD (Northwell Health, Manhasset, NY), called the process “nothing short of chaotic,” particularly the lack of a central location to find out information on all of the available programs and spots. “A lot of it comes down to word of mouth,” he lamented to TCTMD, “and cold emailing programs asking if they're going to be opening up and what their time line is.”

This was unlike every other experience he had had thus far applying to residencies and fellowships. “It was really just playing a game and not really knowing who's the winner and who's the loser in all of this,” Omar said.

The interview process itself was taxing, but also told him a lot about the type of program to which he’d be committing. After one interview, “they offered me the position and they needed the decision by that same day before I left,” Omar recalled. “I was like, ‘Well, I'm going to have to talk to my wife about this.’ And they're like, ‘Oh yeah, go call her and figure it out.’ Clearly that wasn't in line with what I thought would be positive attitudes toward trainees in the future, and it didn't align with me, so I declined.”

Frenchu said she is sympathetic to program directors who feel compelled to fill their slots by offering time-sensitive offers but called that practice “predatory.” She speculated that the current system might be a reflection of the type of field interventional cardiology has become.

“It speaks to some of the competitive mindset that some places might have,” she said. “I do think somehow that not focusing on wellness and work life balance . . . comes through. And if it was family focused, I think it would also probably be more women focused too.”

Omar acknowledged that interventional cardiologists “pride ourselves on being able to stay calm in chaotic situations and really get from one step to the next,” and argued that one reason the field hasn’t moved toward a match system is “just because we're used to that in our daily lives.”

Calls for Change

Many agreed it’s surprising that interventional cardiology is the last subspeciality within cardiology to not use a match system to place fellows into programs.

“It's remarkable that we don't have a match, in my opinion, in interventional cardiology,” Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), told TCTMD. “There's no other word to describe [last year’s process] other than ridiculous. . . . To me, this system seems well due for a change.”

In an informal poll he tweeted last December, Kirtane asked his followers whether they agreed. More than 80% of the 635 respondents replied that they would welcome a match. Subsequent discussions online, as well as a publications in peer-reviewed journals this year, have also began arguing heavily in favor of change.

Both Abbott and Drachman chair the Society for Cardiovascular Angiography and Interventions (SCAI) Interventional Cardiology Match Task Force, formed earlier this year with the goal of moving to a match process for the 2025 cycle. They also are advocating for shifting the application deadline later so that trainees wouldn’t apply until they are done with their second year of general cardiology training, giving them more time to decide in the first place.

In order for these objectives to be approved, 75% of IC programs have to opt in before the end of November. At the time of publication, 44 programs have signed on.

The time is right for a shift because there is a “groundswell [of] belief among the candidates and program directors that something's got to change,” Drachman said. “It's gotten to the point where nobody feels like the ‘old system’ works well. It's just sort of what they've always done.”

Moving the process later “enables the candidate really to understand their career objectives more clearly,” he continued. “It allows them to have more experience, so that people who write their letters of recommendation have a better understanding of their capabilities and their career trajectory and promise. And it also gives people more of a chance to say where do I think I'm going to be a year and a half from now, instead of two [or] two and a half years from now.”

Adnan Khalif, MD (Allegheny Health Network, Pittsburgh, PA), an advanced interventional/cardiac critical care fellow who serves on the SCAI task force, agreed that applying for interventional cardiology during the second year of training may be too early. “As a second-year fellow, you really don't have all that much insight as to what the other programs have to offer in the country,” he told TCTMD. “You know your own program, what they have to offer. And if you find that that aligns with potential career path [and they’re offering you a chance to stay], then you kind of sign on the dotted line, maybe somewhat prematurely.”

As someone who accepted an internal position without looking elsewhere, Khalif watched his peers go through the intense process of interviewing and felt relief that he didn’t have to join them. While he doesn’t regret his choice, he said, “I do sometimes wonder what it would have looked like if I had gone through a formal application process and interviewed around the country with an opportunity to make a rank list.”

Abbott said going to a match will alleviate doubts for applicants, giving them the time to explore all their options without being rushed. But for those who want to stay put, that can still happen. “There is an ability to be honest with the applicants in your own program about your interest in them and their interest in you, and there's no barriers to you ranking your own candidates to match,” she said. “Programs should be reassured that if the applicant is interested in them and they are interested in the applicant, it should all work out in the end just right.”

Even if the specialty goes to a match, the NRMP requires that 75% of available positions be registered with them, leaving some room for external arrangements as well.

Frenchu observed that interventional cardiology has “gotten comfortable” with keeping internal candidates and going to a match might seem “more cumbersome for programs to interview more people or more costly for those applicants. But I think they're the minority, and I think it's sort of done out of convenience because there's all this uncertainty about the process. If you eliminate some of the uncertainty and make this a marriage where both sides want to find the perfect match, that will lift the field.”

A match system will also limit another “disadvantage of the current system,” wherein fellows accept a slot and then continue interviewing. “Programs sometimes don't realize that right now when you offer an applicant a spot, it's really not binding,” Abbott said. “You may have them sign an offer letter, but it does happen that a fellow may take a spot and then a month later be offered a spot that it more optimal for them. There have been instances where then they would take a different spot and it causes a lot of issues. It's obviously not a good practice, but some people are put in bad positions.”

Additionally, Abbott said, a match system will give “a much better way to track the number of applicants and how many programs they applied to, how they matched. Right now, we really have no way to account for it or to keep a record.”

More specifically, Khalif, also a SCAI task force member, said the data gleaned from a match will help with diversity, equity, and inclusion issues in the field. “Another positive of going to the match process is being able to track this data and understand the metrics of how interventional cardiology as a subspecialty performs in that regard,” he said.

Generally, Kutkut argued, a match would potentially make the selection process fairer as well, “because you take more time to select applicants knowing that you submit your rank list at a specific time.

“Maybe it will give a chance to more people or will let them take their time to look at the application,” he said, “and perhaps you are more inclusive or less biased in the selection, too.”

Potential Downsides

Not everyone believes going to a match will be a perfect solution.

Chris Sossou, MD (University of Nevada Las Vegas), a third-year general cardiology fellow who applied for interventional cardiology last cycle, purposefully sought out programs that took applications outside of ERAS.

“I did not apply via ERAS because, one, it's too expensive and I don't have the money to do that, and two, I wanted to apply directly to programs who were accepting applications,” he told TCTMD, adding that this did take more effort. “My reasoning was, if I can apply directly to a program and if that program called me for an interview, that program is genuinely interested in me.”

ERAS already charges a total of $115 per applicant for applying to up to 10 fellowship programs plus some additional transcript fees and taxes. After that, applicants are charged $17 each for programs 11-20, $20 for programs 21-30, and $26 each for 31 or more programs. For the match itself, the NRMP charges additional fees including $70 for registration and $30 per program ranked over 20.

Khalif agreed the current ERAS fees are already “pretty expensive,” though he noted that moving to a match “is part of the evolution of interventional cardiology as a subspecialty. I think we need to move away from the old way of thinking.”

It's your career, it's your future. It matters a lot. Sabeeda Kadavath

“I wish we did not have to pay, because I feel like I've spent so many thousands of dollars already on exams and everything,” Kadavath added. But if spending a bit more would simplify the process, “I think that is something I would still be keen on doing rather than go through this madness of having to decide and not having a good match process,” she said. “Eventually it's your career, it's your future. It matters a lot.”

Kutkut agreed that any additional fees would be “worth the peace of mind.”

Some, like Frenchu, said they did like the comfort of knowing where they’d be so early in the process without the annoyance of having to wait for match results. “That being said, I don't need to know 2 years in advance where I'm going to end up,” she specified.

Others, like Sossou, said they preferred the security of knowing where they’d be moving to a full year-and-a-half in advance. “At this point in your career when you're applying to interventional cardiology fellowship, you are already established,” he said. “Most of the people who are applying are mature: they have family, they have children, they have a mom and dad who are getting older and need more help. They have to be close by. The match system doesn't guarantee that you're going to be close to relative, that you're going to be in one place and continue your life the way you started it.”

As someone who has been in a long-distance relationship with his wife throughout his general training, Sossou understands geographic sacrifice in the name of career goals. And since interventional training is typically only a year long, “rooting everything up and moving somewhere for 1 year that you have no intention of staying is going to be devastating, in my opinion,” he said. “Who knows how many relationships have been ruined by [the match] process. That's something that most people don't talk about.”

Ultimately, Omar argued, “I don't necessarily think that this is a bad system that we have in place, because the real world is like this. You're going to have to go out and find jobs and interview with different jobs and balance various offers. But I do think in the real world you have some time to kind of ruminate and figure out whether this is the right decision for you.”

Kadavath said “the match is not the ultimate solution, but I think it's one that seems to have more pros than cons at this point in time.”

Advice for Current Applicants

For applicants gearing up for this winter’s interview season, it’s unlikely they will see much improvement over last year.

What helped Kadavath in going through the process was narrowing down her top priorities in a program before going on interviews. “For me, it was important that it's a high-volume place, and it was important that the faculty and the environment I was in were supportive and very encouraging of my academic interests,” she said. “So that helped me narrow it down.”

Frenchu suggested being “really honest with the programs, most importantly. I think you have to take the interview as the most important and serious part of the process.” She advised not hesitating to call or email programs of interest if other offers come in before future interview dates. “In the past, you had to go through the secretary of the program, who is used to managing and coordinating everything,” she said, but now it makes more sense to reach out to the program director directly or have a mentor do it.

Who knows how many relationships have been ruined by [the match] process. That's something that most people don't talk about. Chris Sossou

Despite how tempting it might be to an accept an offer and then continue to interview, Omar advised against the practice. “The issue is that you're in a profession where, one, everybody knows each other, [and two], you're very early in your career,” he said. “You do not want to stake your reputation on being the person who broke their commitment.”

Sossou had some advice for program directors based on what he observed last year. “If you're going to offer people interviews, don't offer [both] hybrid zoom or in person,” he said. “To me, it's a false choice and that choice will always favor the person with the most resources.”

Current applicants might be “stuck with the process at hand,” Abbott said, though she urged them to consider providing feedback to the SCAI task force about the challenges they face. “I'm interested to see whether there will be more flexibility this season with these rapid fire offers and time lines, and see whether programs are listening to the candidates about some of these pressures.”

Drachman, too, is optimistic about seeing things change. “I hope that there is a way that all programs can comport themselves with a kind of a courtesy and commitment to the benefit of the fellows so that they don't feel pressured, and they have time to think,” he said. “I don't know if that's going to be the outcome, but for this year, I think that's the best that we can hope for.”