- Email: [email protected]
A Year to Learn It All
JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 9, NO. 19, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2016.08.032
FELLOWS PAGE
A Year to Learn It All A Call-to-Action for a Comprehensive, Yet Not Longer, Training of the Next Generation of Interventional Cardiologists Georges Ephrem, MD, MSC,a Akram W. Ibrahim, MDa,b
Two recent fellows in training (just graduated)
As such, calls have been issued to revisit the inter-
express their views on the structure and duration
ventional cardiology fellowship training, including
of training. We welcome other opinions.
accreditation and funding for a 24-month program (3).
A
—Spencer King III, MD year to learn it all. In the United States, the duration of interventional cardiology fellowship is 12 months as mandated by the Accred-
itation Council for Graduate Medical Education (ACGME). Interventional Fellows-in-Training (iFIT) should perform at least 250 procedures encompassing percutaneous coronary interventions including “the application and usage of balloon angioplasty and stents, along with Doppler flow, intracoronary pressure measurement and monitoring, coronary flow reserve, and intravascular ultrasound” (1). Additionally, iFIT provide comprehensive periprocedural care for patients during outpatient clinic visits. These requirements are essential as they provide a standardized minimum of competency. The tremendous expansion in the field of interventional cardiology raises valid concerns over the applicability of the aforementioned guidelines. Whereas the volume of percutaneous coronary interventions has reached a plateau (2), the prevalence of transcatheter percutaneous technologies spanning peripheral vascular disease and complex valvular heart disease is on the rise as more patients with prohibitive and moderate surgical pathologies previously treated medically are now included.
Inasmuch as it is crucial to maintain training in phase with the development of the field, there are reservations regarding lengthening the training duration. Discussions about additional years of training should be made with utmost delicateness. The published reports has described the conundrum faced by trainees in our field with longstanding debt, lengthening training, and decreasing income (4). iFIT are not deterred by the hazards of the job or the inconvenience of the lifestyle. They have persisted on this lengthy path for a desire to extensively but efficiently learn
the
arts and crafts
of
the subspecialty.
Committed to lifelong learning, they are faced with the stretching of the training process. A 24-month program does not only entail another year of lower income—the estimated annual salary for a new interventional cardiologist being approximately 7 that of a second-year iFIT with similar qualifications (5)—it is especially additional time away from the job market at a period where positions are scarce. In several institutions with a dedicated second year of interventional training, 4 to 6 months are spent on service as part of the duties of a clinical instructor, effectively leaving the iFIT with only one-half a year of actual “hands on” time. No, the solution is in a more comprehensive, yet not longer, training. A growing concern among iFIT pertains to the ACGME minimal requirements limiting the value of their interventional year. Examples of this trend can
a
From the Division of Cardiology, Department of Medicine, Emory Uni-
be found in the literature (3) where learning complex
Southeastern
percutaneous coronary interventions and mechanical
Cardiology Associates, Columbus, Georgia. Both authors have reported
circulatory support is given as a reason for requiring
that they have no relationships relevant to the contents of this paper to
an extra year. The numerous procedure types in cor-
versity School of Medicine, Atlanta, Georgia; and the
b
disclose. Drs. Ephrem and Ibrahim are graduates of the interventional cardiology programs of Oakland University-William Beaumont School of
onary revascularization, from different plaque modi-
Medicine and Emory University School of Medicine, respectively.
fication techniques to various circulatory support
Ephrem and Ibrahim
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 9, NO. 19, 2016 OCTOBER 10, 2016:2074–5
Fellows Page
platforms, and the ever growing complexity of the
scrub technicians, and general cardiology fellows)
lesions should be part of any 1-year interventional
should be implemented. Understandably, for a man-
training
specifically
ager or an administrator, with a financial perspective
mentioned in the ACGME requirements. As for the
and a tight budget, a second-year iFIT is the ideal
structural and peripheral techniques, this is the most
option, especially when the estimated salaries for
opportune time to make them officially an integral
interventional nurse practitioners or physician assis-
whether
or
not
they
are
part of the interventional year. Given the trend in
tants are 2 and 4 that of a trainee, respectively (5).
decreasing numbers of coronary interventions (2) and
The optimal training is that which provides a
the consequent decrease in the numbers of fellowship
balanced “hands-on,” “first operator” experience to
training spots, enriching an interventional year with
complement periprocedural patient care. If additional
peripheral
training is pursued, it should be to cross a qualitative
and
structural
technique
acquisition
threshold toward more “niche” career paths such as
would be a judicious use of the iFIT’s time. Some might argue that there are too many procedures to be mastered in a single year of training because
structural
and
peripheral
advanced heart failure and transplant or adult congenital heart disease.
interventions
As recent graduates from interventional training,
include a flurry of transcatheter therapies each with
we have a privileged position to view what is now and
its own learning curve. From this perspective, the
what we believe should be in the future. Interven-
logic advocating an additional year of training may
tional cardiology fellowship should be an intense,
seem sound. However, the training paradigm is
rich, 1-year-only training program focused on skills
shifting (6) and so should our outlook. The glaring
set acquisition in coronary, peripheral, and structural
example for this new prism is the new COCATS (Core
interventions. We rely on ACGME to continue advo-
Cardiovascular Training Statement) promoting a phi-
cating for trainees’ education. The optimal way to do
losophy of competency rather than number per-
so is not to give in to the trend in fragmentation of
formed (7). Along similar lines, eminent educators in
training by funding a 24-month curriculum but by
the interventional realm speak abundantly about
updating its requirements to ensure fellowship pro-
training as acquisition of key skills sets (“the basics”)
grams provide the whole spectrum of skills acquisi-
and the translocation of these core techniques
tion. Once out of training, our commitment to lifelong
between procedures (8). They refer to the first 3 to 5
learning as well as the mandated requirements for
years of clinical practice as the true “end of training”
accreditation in the various devices or procedures
regardless of the intensity of exposure during
will lead us to the refinement of our career path. This
fellowship. From this perspective, a comprehensive
can be through the mentors, courses, or dedicated
training can be achieved in 1 year. This would obvi-
workshops. In a nutshell, more learning through a
ously require that training programs are conceived
comprehensive, yet not longer, training: That is the
accordingly. For example, the outpatient experience
future we long for.
should
be
a
specialty clinic
(interventional
or
peripheral or structural) that provides incremental
ADDRESS
education. If paperwork (e.g., admission notes,
Ephrem, Division of Cardiovascular Disease, Depart-
discharge summaries, prescriptions) and assistance in
ment of Medicine, Emory University School of Medi-
diagnostic procedures are monopolizing too much
cine,
time, then proper delegation (midlevel providers,
Georgia 30322. E-mail: [email protected].
101
CORRESPONDENCE
Woodruff
Circle,
TO:
Suite
Dr.
319,
Georges
Atlanta,
REFERENCES 1. ACGME. ACGME Program Requirements for Graduate Medical Education in Interventional Cardiology (Internal Medicine). Available at: https://www.acgme.org/Portals/0/PFAssets/ ProgramRequirements/152_interventional_card_
3. Kalra A, Bhatt DL, Pinto DS. Accreditation and funding for a 24-month advanced interventional cardiology fellowship program: a call-to-action for optimal training of the next generation of interventionalists. Catheter Car-
int_med_2016_1-YR.pdf. Accessed August 17, 2016.
diovasc Interv 2016 Aug 12 [E-pub ahead of print].
2. Kim LK, Feldman DN, Swaminathan RV, et al. Rate of percutaneous coronary intervention for the
4. Ephrem G. A career of lifelong learning, not lifelong training: an early cardiologist’s perspective. J Am Coll Cardiol 2015;65:2664–6.
7. Halperin JL, Williams ES, Fuster V. COCATS 4 Introduction. J Am Coll Cardiol 2015;65: 1724–33.
5. Peckham C. Medscape Cardiologist Compensation Report 2016. Available at: http://www.medscape.
8. Ephrem G. A year to learn it all: it is the basics. J Am Coll Cardiol Intv 2016;9:755–6.
management of acute coronary syndromes and stable coronary artery disease in the United States (2007–2011). Am J Cardiol 2014;114:1003–10.
com/features/slideshow/compensation/2016/cardio logy. Accessed August 17, 2016. 6. Ibrahim
AW.
The
dynamic
and
evolving
realm of interventional cardiology: a fellow-intraining’s perspective. J Am Coll Cardiol Intv 2015;8:1402–3.
2075
VOL. 9, NO. 19, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2016.08.032
FELLOWS PAGE
A Year to Learn It All A Call-to-Action for a Comprehensive, Yet Not Longer, Training of the Next Generation of Interventional Cardiologists Georges Ephrem, MD, MSC,a Akram W. Ibrahim, MDa,b
Two recent fellows in training (just graduated)
As such, calls have been issued to revisit the inter-
express their views on the structure and duration
ventional cardiology fellowship training, including
of training. We welcome other opinions.
accreditation and funding for a 24-month program (3).
A
—Spencer King III, MD year to learn it all. In the United States, the duration of interventional cardiology fellowship is 12 months as mandated by the Accred-
itation Council for Graduate Medical Education (ACGME). Interventional Fellows-in-Training (iFIT) should perform at least 250 procedures encompassing percutaneous coronary interventions including “the application and usage of balloon angioplasty and stents, along with Doppler flow, intracoronary pressure measurement and monitoring, coronary flow reserve, and intravascular ultrasound” (1). Additionally, iFIT provide comprehensive periprocedural care for patients during outpatient clinic visits. These requirements are essential as they provide a standardized minimum of competency. The tremendous expansion in the field of interventional cardiology raises valid concerns over the applicability of the aforementioned guidelines. Whereas the volume of percutaneous coronary interventions has reached a plateau (2), the prevalence of transcatheter percutaneous technologies spanning peripheral vascular disease and complex valvular heart disease is on the rise as more patients with prohibitive and moderate surgical pathologies previously treated medically are now included.
Inasmuch as it is crucial to maintain training in phase with the development of the field, there are reservations regarding lengthening the training duration. Discussions about additional years of training should be made with utmost delicateness. The published reports has described the conundrum faced by trainees in our field with longstanding debt, lengthening training, and decreasing income (4). iFIT are not deterred by the hazards of the job or the inconvenience of the lifestyle. They have persisted on this lengthy path for a desire to extensively but efficiently learn
the
arts and crafts
of
the subspecialty.
Committed to lifelong learning, they are faced with the stretching of the training process. A 24-month program does not only entail another year of lower income—the estimated annual salary for a new interventional cardiologist being approximately 7 that of a second-year iFIT with similar qualifications (5)—it is especially additional time away from the job market at a period where positions are scarce. In several institutions with a dedicated second year of interventional training, 4 to 6 months are spent on service as part of the duties of a clinical instructor, effectively leaving the iFIT with only one-half a year of actual “hands on” time. No, the solution is in a more comprehensive, yet not longer, training. A growing concern among iFIT pertains to the ACGME minimal requirements limiting the value of their interventional year. Examples of this trend can
a
From the Division of Cardiology, Department of Medicine, Emory Uni-
be found in the literature (3) where learning complex
Southeastern
percutaneous coronary interventions and mechanical
Cardiology Associates, Columbus, Georgia. Both authors have reported
circulatory support is given as a reason for requiring
that they have no relationships relevant to the contents of this paper to
an extra year. The numerous procedure types in cor-
versity School of Medicine, Atlanta, Georgia; and the
b
disclose. Drs. Ephrem and Ibrahim are graduates of the interventional cardiology programs of Oakland University-William Beaumont School of
onary revascularization, from different plaque modi-
Medicine and Emory University School of Medicine, respectively.
fication techniques to various circulatory support
Ephrem and Ibrahim
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 9, NO. 19, 2016 OCTOBER 10, 2016:2074–5
Fellows Page
platforms, and the ever growing complexity of the
scrub technicians, and general cardiology fellows)
lesions should be part of any 1-year interventional
should be implemented. Understandably, for a man-
training
specifically
ager or an administrator, with a financial perspective
mentioned in the ACGME requirements. As for the
and a tight budget, a second-year iFIT is the ideal
structural and peripheral techniques, this is the most
option, especially when the estimated salaries for
opportune time to make them officially an integral
interventional nurse practitioners or physician assis-
whether
or
not
they
are
part of the interventional year. Given the trend in
tants are 2 and 4 that of a trainee, respectively (5).
decreasing numbers of coronary interventions (2) and
The optimal training is that which provides a
the consequent decrease in the numbers of fellowship
balanced “hands-on,” “first operator” experience to
training spots, enriching an interventional year with
complement periprocedural patient care. If additional
peripheral
training is pursued, it should be to cross a qualitative
and
structural
technique
acquisition
threshold toward more “niche” career paths such as
would be a judicious use of the iFIT’s time. Some might argue that there are too many procedures to be mastered in a single year of training because
structural
and
peripheral
advanced heart failure and transplant or adult congenital heart disease.
interventions
As recent graduates from interventional training,
include a flurry of transcatheter therapies each with
we have a privileged position to view what is now and
its own learning curve. From this perspective, the
what we believe should be in the future. Interven-
logic advocating an additional year of training may
tional cardiology fellowship should be an intense,
seem sound. However, the training paradigm is
rich, 1-year-only training program focused on skills
shifting (6) and so should our outlook. The glaring
set acquisition in coronary, peripheral, and structural
example for this new prism is the new COCATS (Core
interventions. We rely on ACGME to continue advo-
Cardiovascular Training Statement) promoting a phi-
cating for trainees’ education. The optimal way to do
losophy of competency rather than number per-
so is not to give in to the trend in fragmentation of
formed (7). Along similar lines, eminent educators in
training by funding a 24-month curriculum but by
the interventional realm speak abundantly about
updating its requirements to ensure fellowship pro-
training as acquisition of key skills sets (“the basics”)
grams provide the whole spectrum of skills acquisi-
and the translocation of these core techniques
tion. Once out of training, our commitment to lifelong
between procedures (8). They refer to the first 3 to 5
learning as well as the mandated requirements for
years of clinical practice as the true “end of training”
accreditation in the various devices or procedures
regardless of the intensity of exposure during
will lead us to the refinement of our career path. This
fellowship. From this perspective, a comprehensive
can be through the mentors, courses, or dedicated
training can be achieved in 1 year. This would obvi-
workshops. In a nutshell, more learning through a
ously require that training programs are conceived
comprehensive, yet not longer, training: That is the
accordingly. For example, the outpatient experience
future we long for.
should
be
a
specialty clinic
(interventional
or
peripheral or structural) that provides incremental
ADDRESS
education. If paperwork (e.g., admission notes,
Ephrem, Division of Cardiovascular Disease, Depart-
discharge summaries, prescriptions) and assistance in
ment of Medicine, Emory University School of Medi-
diagnostic procedures are monopolizing too much
cine,
time, then proper delegation (midlevel providers,
Georgia 30322. E-mail: [email protected].
101
CORRESPONDENCE
Woodruff
Circle,
TO:
Suite
Dr.
319,
Georges
Atlanta,
REFERENCES 1. ACGME. ACGME Program Requirements for Graduate Medical Education in Interventional Cardiology (Internal Medicine). Available at: https://www.acgme.org/Portals/0/PFAssets/ ProgramRequirements/152_interventional_card_
3. Kalra A, Bhatt DL, Pinto DS. Accreditation and funding for a 24-month advanced interventional cardiology fellowship program: a call-to-action for optimal training of the next generation of interventionalists. Catheter Car-
int_med_2016_1-YR.pdf. Accessed August 17, 2016.
diovasc Interv 2016 Aug 12 [E-pub ahead of print].
2. Kim LK, Feldman DN, Swaminathan RV, et al. Rate of percutaneous coronary intervention for the
4. Ephrem G. A career of lifelong learning, not lifelong training: an early cardiologist’s perspective. J Am Coll Cardiol 2015;65:2664–6.
7. Halperin JL, Williams ES, Fuster V. COCATS 4 Introduction. J Am Coll Cardiol 2015;65: 1724–33.
5. Peckham C. Medscape Cardiologist Compensation Report 2016. Available at: http://www.medscape.
8. Ephrem G. A year to learn it all: it is the basics. J Am Coll Cardiol Intv 2016;9:755–6.
management of acute coronary syndromes and stable coronary artery disease in the United States (2007–2011). Am J Cardiol 2014;114:1003–10.
com/features/slideshow/compensation/2016/cardio logy. Accessed August 17, 2016. 6. Ibrahim
AW.
The
dynamic
and
evolving
realm of interventional cardiology: a fellow-intraining’s perspective. J Am Coll Cardiol Intv 2015;8:1402–3.
2075