Survey Offers Clues to Waning Appeal of Acute HF/Transplant Fellowships

A survey of American College of Cardiology trainees provides new insights into why advanced heart failure and transplant cardiology (AHFTC) fellowships are struggling to fill spots. Responses from fellows indicate, for example, that many are interested in critical care and cardiogenic shock, but non-heart failure fellows put less emphasis on patient acuity/complexity and more on lifestyle factors, including geographic location, compensation, and work schedule.

As previously reported by TCTMD, more than half of the AHFTC fellowship positions in the US went unfilled in 2022, despite burgeoning numbers of patients with advanced heart failure needs. Earlier this year, heart failure leaders published a “road map” in the Journal of Cardiac Failure (JCF) for revamping interest in their subspecialty, including calls for more data to understand the waning interest in the field.

Olivia Gilbert, MD (Atrium Health Wake Forest Baptist, Winston-Salem, NC), and colleagues published the results in JACC: Heart Failure last week, to coincide with an ePoster presentation at the Heart Failure Society of America (HFSA) annual scientific meeting. Speaking with TCTMD, Gilbert noted that while the plan to conduct this survey arose independently from the road map initiative published in JCF, she and her co-authors ultimately worked with the JCF perspective authors to hone their survey questions.

Key Differences

In all, 419 fellows responded to the 44-point survey, representing 8% of fellows in training. Seventy-eight of these were AHFTC fellows, while 341 were non-AHFTC respondents. Nearly half were white and 64% were men, with a mean age of 32.8. Notably, said Gilbert, women made up a larger proportion of the AHFTC responders than the non-AHFTC respondents.  

For Gilbert, one of the most striking findings of the survey was the high level of interest in critical care cardiology and cardiogenic shock expressed by both heart failure and non-heart failure fellows. “I was surprised by how uniformly captivating critical care and cardiogenic shock were to both sides: those interested in heart failure and those pursuing non-heart failure careers,” she said. “I really think that’s a gateway of opportunity to captivate interest in heart failure if we're to really embrace the expertise in that field.” Transplant, she noted, was not as big a draw for the non-AHFTC respondents.

Positive role models was the highest rated career characteristic for both groups; AHFTC respondents put a greater emphasis on research and administrative opportunities, whereas more non-AHFTC fellows said that work schedules, compensation, and geographic flexibility were highly ranked factors for them.

Speaking to compensation, Gilbert pointed out what others have said before, that heart failure is not a high direct-RVU subspeciality, despite the impact advances in HF care are having on downstream effects. As such, the survey data support discussions aimed at revising heart failure compensation models, in terms of the “pure economics” of the equation. “Heart failure is the fastest growing and most expensive Medicare diagnosis, yet we're seeing this suggested decline in heart failure providers,” she said. “At a certain point, we have to meet the demand, or the compensation for that supply must go up.”

Back in April, the HFSA convened a consensus conference of the AHFTC Fellowship Task Force with the aim of developing “strategies to increase the value proposition of an AHFTC fellowship.”

A summary of their recommendations was published earlier this month in JCF, Gilbert noted, adding that she thinks a key next step will be to consider their survey results alongside data gathered from specialists already working in the field to understand the extent to which fellows’ perceptions match reality.