November 2005: Point/Counterpoint on a Fast-Track Residency Program for Cardiology

Carol Peckham

Disclosures

November 21, 2005

I am pleased to introduce our first "Point/Counterpoint" feature, a discussion on a fast-track cardiology residency program.

The American College of Cardiology has developed a multipronged strategy for increasing the supply of cardiologists, including a proposal to create a 5-year "fast-track" residency program that would drop 1 year of internal medicine training. Such a program, however, could cause difficulties for the field of internal medicine, which could lose some third-year residents who provide extensive patient care. Furthermore, some physician workforce experts question the need for more specialists. A recent study in Health Affairs[1] supports other research that concludes that more primary care doctors are needed and not more specialists.

To address this debate, we have invited expert representatives from the cardiology and internal medicine specialties to offer their opinions on this important subject.

On Point, we welcome W. Bruce Fye, MD, MA, MACC, Professor of Medicine and Medical History at the Mayo Clinic College of Medicine in Rochester, Minnesota. Dr. Fye is also past-president of the American College of Cardiology and Editor and Conference Chair of the 35th Bethesda Conference: Cardiology's Workforce Crisis: A Pragmatic Approach.

Dr. W. Bruce Fye: The American College of Cardiology has developed a multipronged strategy for increasing the supply of cardiologists. This strategy is spelled out in the 35th Bethesda Conference Report on Cardiology's Workforce Crisis.[2] One part of the ACC's strategy is a proposal to pilot a 5-year "short-track" combined internal medicine cardiology fellowship training program designed to produce general clinical cardiologists. The first 2 years would be core training in internal medicine, and the middle year (cardiovascular medicine) would emphasize medical rotations of value to cardiologists, such as management of lipid disorders. The final 2 years would be devoted to "core training in cardiology." The logistics need to be worked out, but before that can be done we need approval from the ABIM [American Board of Internal Medicine], the ACGME [Accreditation Council for Graduate Medical Education], and the RRC [Residency Review Committee]. Without that, we cannot identify programs willing to develop innovative options to the current structure and recruit residents to fill the slots in this new pathway.

There's no question that we are facing an increasing problem in cardiology care because of a growing mismatch in the supply of and demand for cardiovascular specialists. Simply stated, not enough clinical cardiologists are being trained to take care of an aging population. How do we train more cardiologists who will function as clinical cardiologists rather than going into interventional or electrophysiology? We are interested in training more cardiologists who would function as consultants, perform certain noninvasive imaging tests such as transthoracic echocardiography and, possibly, perform diagnostic coronary angiography, depending on the physician's interests, training, and needs in the community where he or she plans to practice. General clinical cardiologists would also emphasize prevention.

In order to attract more people who would be interested in this area, we have to look at length of training. I'm a medical historian as well as a practicing clinical cardiologist. From my perspective, it's time to reassess the structure, content, and length of training that is appropriate and realistic for training cardiologists in the early 21st century. As internal medicine training has evolved in the past 10-15 years there has been increasing emphasis on training internists for the practice of outpatient internal medicine with a focus on the delivery of primary care. This has led to the introduction of certain procedural requirements during internal medicine residency that are irrelevant to individuals who want to be cardiologists. There is no reason to expect an individual planning on a career in cardiology to perform bone marrow aspirations and joint aspirations. Yet, that is what they must do at this time to comply with ACGME, RRC, and ABIM requirements if they hope to become certified in internal medicine...and they must pass their internal medicine boards if they ever hope to be certified by the ABIM in cardiology.

Ideally, patients will have a primary care physician who will work collaboratively with a cardiologist to provide high-quality care to the ever-growing population of patients with cardiovascular disease. From my point of view, there is growing unease in the internal medicine community because they are facing several trends that make it increasingly difficult for them to identify their focus and mission. Family physicians and skilled nurse practitioners and other nonphysician clinicians are providing primary care. Hospitalists, a group that did not exist in 1990, are rapidly assuming a dominant role in the management of inpatients with general medical problems. Most medical graduates view internal medicine as a pathway to becoming a specialist in some medical field, such as cardiology or gastroenterology.

Another issue is the paradigm where you have a department of medicine that oversees a cardiovascular division in an academic structure. For all practical purposes, this hierarchical structure does not exist outside of academic medical centers. Today, almost one half of US cardiologists practice in single specialty groups. Personally, I have spent my career in large multispecialty group practice and believe that that model has many advantages when it comes to patient care. Regardless of the setting, cardiologists being trained today do not want to function as primary care physicians. We hope that the 5-year short-track program for training general clinical cardiologists could be piloted at a few medical centers where the training program directors of internal medicine and the chairs of those divisions are willing to help invent a new pathway that will attract individuals interested in careers in general clinical cardiology. We cannot be sure, without a pilot, how many individuals would consider such a career path. Currently, a majority of cardiology trainees want to become interventional cardiologists or electrophysiologists. There are many reasons for this, and one is the reimbursement system that encourages individuals to choose procedural subspecialties of cardiology.

On Counterpoint, we welcome Lawrence G. Smith, MD, FACP, Chair of the Education Committee of the American College of Physicians, and Chief Academic Officer and Senior Vice President of Academic Affairs at North Shore-Long Island Jewish Health System in Great Neck, New York.

Dr. Lawrence G. Smith: I would like to take this opportunity to respond to the proposal put forth by Dr. Fye. This proposal and the subsequent arguments need to be analyzed based on 3 fundamental questions: (1) what are the needs (ie, what is best) for patient care; (2) what is best for the trainees and what untoward effects could these proposals create; and (3) would the proposal be effective at achieving its intended goal, ie, to increase the number of general cardiologists.

The American College of Physicians agrees that we must be able to provide physicians capable of caring for the aging population. However, what typically characterizes these patients is not any isolated medical problem, limited to a single organ system (such as the cardiovascular system), but rather a number of complex, chronic, and interacting medical problems that require an understanding that extends beyond a single organ system. The physician must be able to apply an integrative approach to patient care, focusing on the whole patient rather than on just one organ system, and taking into account interactions among diseases, between diseases and drugs, and among the multiple drugs taken by the patient. In the specific circumstance where the patient's primary problem is cardiac, it may be appropriate for a general cardiologist to be the primary caregiver. However, the cardiologist must then have a sufficient background in the core discipline of internal medicine to understand the complex interactions just described, and must be able to evaluate other undifferentiated or common problems as they arise, without the need to refer to a different organ-based subspecialist for each and every new problem. Unfortunately, shortening training by a year will only make the cardiologist less experienced and capable of handling these complex, multisystem issues, not more capable. Further, much of what is described as clinical cardiology is the traditional practice domain of the internist. Considering the enormous need for complex care integration of the ever-aging population, there seems to be little reason that these areas of clinical cardiology should not remain as part of the usual practice of the internist.

Thus, we feel that the interests of patients are best served with highly trained internists; when it is likely that subspecialists might function as principal caregivers, they should continue to have 3 years of core training in internal medicine before pursuing subspecialty training. Most subspecialists today are training to practice either exclusively in their subspecialty as consultants and proceduralists, or in delivering concurrent care with primary care physicians for highly specialized conditions. We believe that there should be a legitimate debate as to whether specialists who will be exclusively proceduralists, and never principal caregivers, could reduce the length of pre-fellowship training. However, this was not the thrust of Dr. Fye's argument. We do agree, however, that within the 3 years of internal medicine residency there should be a period of customized training during the third year, which provides those broader internal medicine experiences that will be most valuable to the trainee in his or her eventual role as a subspecialist. This third year (which Dr. Fye labels as the "middle year") should be under the umbrella of the internal medicine residency training program, not the cardiovascular fellowship training program, in order to best achieve the objectives of this year, especially the maturation of clinical reasoning and the skills to lead complex care teams. This year should not simply become an earlier or extra year of focus on organ-based subspecialty training.

In terms of the residents, the need to make a career choice 1 full year earlier will put enormous and possibly unnecessary pressure on young physicians to decide before they have appropriate clinical experience in the many subspecialty areas of medicine. Further, residency programs might be disinclined to match trainees who express strong interest in cardiology because these trainees would then leave the program early, creating manpower and scheduling problems for the program. It is possible that the most competitive programs, capable of recruiting a large number of superlative candidates, would exercise this option most frequently. Residency programs would find it difficult to plan rotation schedules and staff teaching services in a predictable way with an unknown, fluctuating, and potentially significant number of residents leaving a year early. Finally, cardiology fellowship programs would have to make admission decisions with little substantive information as to the clinical skills, leadership skills, and future potential of the residents since they would have just completed internship at the time of application.

In considering the third question, we do not believe that the proposed "short-track" cardiology training would achieve its intended goal, ie, to increase the number of general clinical cardiologists. First of all, the length of internal medicine training prior to cardiology fellowship is not at all a limiting factor for the number of medical residents pursuing cardiology. Because of its relatively high reimbursement and the high-technology nature of the practice, cardiology remains a particularly attractive and competitive subspecialty fellowship, and there is no dearth of residents to fill the available slots. Rather, the bottleneck is with the number of cardiology fellowship positions that are available, not the number of interested applicants. If residency training were shortened from 3 years to 2 years prior to fellowship training, this would create a single-year glut of applicants for an already bottlenecked situation. In that particular year there would be twice as many applicants with no increase in cardiology slots; this would simply add enormous stress to the applicant pool that year without producing a single additional cardiologist.

In addition, at present only a very small minority of trainees entering a cardiology fellowship eventually become general (ie, nonprocedural) cardiologists. Rather, because reimbursement is substantially higher for "proceduralists" and because high-tech procedural fields are uniquely attractive to young physicians, cardiology trainees overwhelmingly pursue careers in interventional cardiology and electrophysiology, not general cardiology. Until the current dysfunctional payment system appropriately rewards physicians for their cognitive -- as opposed to procedural -- services and the profession of medicine gives equal prestige to cognitive specialties as it does to procedural fields, there would be little incentive for trainees to change the current pattern of career choice. In fact, expanding the number of cardiology trainees to flood the market with too many graduating fellows in order to "force" a subgroup of these fellows into undesirable career choices is extremely bad health manpower strategy. Therefore, even if more cardiology training positions were available, the likely result would be a continued increase in procedural cardiologists, not general cardiologists. If the number of cardiology fellows increased extraordinarily such that the procedural market was saturated, it is true that cardiologists might, by default, be forced into general cardiology practices, but this would not be by choice. Shortening internal medicine training before fellowship would only exacerbate the problem, since a trainee with less general background would be attracted to a more focused career path (ie, interventional cardiology or electrophysiology) rather than to general cardiology, where a broader base of training is needed.

We welcome your responses on this issue. If you also have other comments or questions, please contact me at cpeckham@medscape.net .

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