How to Train Your Cardiology Fellow

; Duane S. Pinto, MD, MPH


March 02, 2015

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Change in the Air in Academic Cardiology

Robert A. Harrington, MD: This is Bob Harrington from Stanford University, here on and Medscape Cardiology.

We all come from academic medical centers, but we choose different career paths. For those of us who have stayed within the university system, changes are under way in how hospitals are reimbursed for care that have direct implications for our residency and fellowship programs, and in how academic faculty divide up their time. There are changes in the type of doctors who practice in the intensive care unit. How will these changes affect the training of our cardiovascular fellows?

Joining me is the perfect guest to have this discussion, because he has held many roles in academic medicine. Duane Pinto is an interventional cardiologist and associate professor of medicine at Harvard University. He is director of the Cardiac Care Unit at the Beth Israel (BI) Deaconess Medical Center, and he has held leadership positions throughout the cardiovascular community, including in the American Heart Association and the American College of Cardiology (ACC) and on some of our journals.

For many years, Dr Pinto directed the fellowship training program at BI Deaconess, one of the great cardiology training programs. Lately, you have moved into a broader role within the BI and Harvard system, putting you more in a leadership and policy position, where you are involved in such issues as recruitment and retention of faculty.

If you are department chair or a division chief, every one of your peers and colleagues will tell you that the single most important thing you have to do in your job is recruit and retain an excellent faculty. Let's talk about that from your perspective.

Duane S. Pinto, MD, MPH: That is a very important factor when it comes to any leadership position—even outside of academic medical centers, in your practice or in any area where you want to have talent, because talent is what makes the machine work efficiently and effectively. In academic medicine, it goes back to what you initially introduced as the quality of your fellowship and the trainees, because that is how you get the best and the brightest of your young faculty to keep the faculty vibrant.

That is what has become challenging over the past several years. You know this well as a chairman of medicine at an academic medical institution, that the ability to fund young investigators and young faculty at the most vulnerable point—the beginning of their careers—has become very difficult as healthcare budgets have declined; as academic budgets to support faculty, for example, with bridge funding, have decreased and reimbursements have gone down.

As we have entered an era of performance-based metrics with respect to productivity, I find that a lot of emphasis has been placed on clinical productivity. A person's salary is often defined by their productivity, and their value to the division or the practice. In some cases, that is appropriate, and in some cases, it isn't.

All those in leadership positions are having a hard time maintaining the existing faculty with competitive wages, as well as finding a way to recruit young talent.

Is Training Too Long?

Dr Harrington: You have hit upon a number of points that I am going to try to tease out and get further reflection upon. One thing is the challenge for a young person moving from a fellowship training position to a faculty role. It is becoming clear that the length of time that we are asking our medical students, house officers, and fellows to train is becoming unsustainable.

The typical interventional cardiologist completes 4 years of medical school and 3-4 years of residency (depending upon his or her background work), and then goes off to a fellowship. They do at least 3, if not 4, years of general fellowship (which may have included some research), and then 1 or 2 years of interventional fellowship. At that point, our senior fellows are postgraduate year 10's (PG-10s)—conservatively, 8-10.

It is no surprise that what we are seeing as we look at the job market—particularly the academic job market, according to the newest figures from National Institutes of Health (NIH)—is that the first NIH grant for a physician investigator comes at age 43. This isn't sustainable, is it?

Dr Pinto: It's not. I see the fellows struggling with how to address this concern. Several strategies have been employed, and I would love to hear from you as an experienced leader and mentor in academics.

When there are fellows who need to compete for limited available jobs, one of the strategies is to accumulate more expertise. In other words, I need to make myself more marketable, so I should obtain nuclear training, CT training, or MRI training. For interventional cardiologists, maybe I would obtain training in imaging modalities, such as transesophageal echocardiography. Every interventionalist can do coronary angioplasty. How do you distinguish yourself? You could sign up for an additional year of structural or peripheral vascular interventional training, but I find that to be a less effective strategy than focusing on one or two areas.

At the same time, we still ask our trainees to have a broad base of education and a broad knowledge base, so it is a conundrum for both trainees and the faculty who are advising them. I would love to hear your thoughts on this.

Dr Harrington: The average medical student in this country is leaving medical school about $150,000 in debt. Much of that debt is deferred throughout those periods of training, so now they are not only looking at a faculty job and moving from a trainee level salary, but the debt is going to become due. They are essentially looking at a mortgage and thinking, how do I pay off this educational debt, at the same time that I would like to move into a house and start saving for my children's college and do all the other things that are a part of daily living? It is becoming quite difficult.

Advice for the Scholarly Inclined

Dr Harrington: Let me return to your question about how to do this. In many places, our fellows are overskilling themselves. I read recently that the average cardiology fellow is taking two and half to three board exams—internal medicine and general cardiology, and maybe they are doing interventional cardiology, electrophysiology, advanced heart failure, or nuclear cardiology. They are taking all sorts of certifying examinations in an attempt to make themselves more marketable.

I tell people who are interested in academic medicine, "If you really want to go the scholarship route, you have to acquire some skills that will allow you to compete in a world of grants and contracts. Frankly, the only way to do that, if you are really serious about scholarship, is to acquire the basic training. There is a method by which you do that if you are a clinical scientist. But you have to get advanced training in something that is going to help you be a contributing member of a research team."

The second key piece is to go somewhere where you will be able to join a research team. The days are gone when you hire the young person and say, "Oh, we don't have a clinical trials program. We would like you to start one." That is no longer realistic, given the demands and the challenges. Young people would be better off somewhere where there is an established clinical trials or outcomes research program, joining that group, and continuing their education as junior faculty members, and then positioning themselves for jobs after that. There is no way for people to succeed anymore unless they are part of teams.

Dr Pinto: You are right. As faculty, we have been somewhat remiss in our responsibility in being able to effectively explain this to trainees and give them the understanding about how people get paid in academic medicine and even in private practice.

We often ask people what percentage of clinical work they would like to do, without defining what that means as far as salary support. For example, what would you need from nonclinical activity to supplement that income? We don't explain what a chief of cardiology or a chairman of medicine might be thinking when they define someone's job effort.

We are very good at teaching fellows how to do heart catheterizations, read echocardiograms, and calculate QT intervals, but we don't get very granular in how to look for a job properly and how to negotiate what your job effort is. Yet we ask them to be introspective about what type of job they want, so we are not really preparing them well to compete for these academic positions in the negotiating part of the process.

It is okay for you and I, as established academicians in our institutions, to say this is how to be successful as an academician, because you can learn from Duane Pinto's mistakes. But we also have to be mindful of the fact that our trainees are not sure they are going to find an academic position, because they know that they are oversubscribed, particularly in the areas where people want to live and in the major research arenas. They feel that they need to hedge their bets in case they need to go into private practice.

In that case, they don't want to be left without any skills, but at the same time they don't know what skills they should be acquiring to make themselves competitive. It is a very difficult position for our trainees.

Research: It's Not a Hobby

Dr Harrington: You have hit on some key issues. Maybe I can offer up some ideas on where to get help. The ACC does a good job, with its emerging leaders program as well as its fellows in training program, of providing career advice, largely at the state level through the state chapters; you are very involved with the state chapter in Massachusetts. These are opportunities to pair young people with more senior physicians to try to learn about the realities of academic practice and private practice.

Under Val Fuster's leadership, the ACC has run a course every December at Heart House called "How to Be a Cardiovascular Investigator," where a lot of these topics are discussed in quite some detail.

We have to do a better job of helping people understand, of demystifying the process. I am fond of saying to faculty and fellows, "There are no magical pots of money in an academic medical center. There are three pots of money. There are clinical dollars, research dollars (grants and contracts, indirect and direct), and philanthropy—and no matter what it is you want to do, the money has to come from one of those buckets."

The other great myth in academic medical center is unfunded time. Someone will say, "I need some unfunded time to do this work." My retort is always, "There is no such thing as unfunded time. Unfunded time is a myth." You expect to get paid for your time. That money has to come from somewhere. It may be unfunded in the sense that research money is not funding the time to work on that project, but something, or somebody, is funding it.

We used to do a lot of this in my former job at the Duke ClinicaI Research Institute when we spent time with the fellows. I called it "Academic Financing 101."

Dr Pinto: That is very true. My wife is a hospital administrator, and she has a nice encapsulating statement that if you have a work effort that you are not being paid for (for example, unfunded research), that is actually a hobby. We all have many hobbies, but if it is going to be a profession, you need to be paid for it.

Dr Harrington: Rob Califf has a variant of that. He says that clinical research is not a hobby. Done well, it has to be a job.

Better Metrics to Ensure Competence

Dr Harrington: Let's discuss what we are doing about training. There is a new version of the Core Cardiology Training Symposium (COCATS) document,[1] which is guiding training. It is out on the web now for public comment. Put your old training fellowship director hat on. Are those documents helpful to you as you think about the requirements to create a competent cardiologist?

Dr Pinto: They are very helpful. They help set the minimum standard that we are trying to achieve in a general, broad-based cardiovascular education. It helps put some boundaries around how many months somebody needs in the echocardiographic laboratory or the consult service. Helping design a curriculum is very valuable.

We have a very busy cath lab, and the fellows are involved in every catheterization case. A metric based on time, indicating that you spend a certain number of months in the cath lab, could be very different for our fellows who do a large volume of cases in a relatively short period. At the same time, in another laboratory, where fellows might do a smaller volume of cases, that time-based measure of competency is probably different.

A pure volume-based standard is also somewhat remiss because with procedures, some people achieve competence after five procedures and some people need 50 procedures. Our assessment tools have to keep up with the changes in training. Our ability to give directed feedback and to use new technology (for example, simulation training and checklists for feedback) can do a lot to advance procedural training and document competence—not only for our referring colleagues but also to document competence on a real basis, rather than on a volume or a time basis.

The other challenge for fellowship directors is expansion in areas that are necessary to train in. For example, not all fellowship programs have the capability to train in such areas as adult congenital heart disease, cardiac MRI, and advanced heart failure in transplant. The time is becoming more laborious for our fellows, and you are part of the writing group for the scholarly activity. As we expand our need for clinical training, we have to erode elective and scholarship time if we are still going to keep the fellowship at 36 months.

That is one of many challenges for fellowship directors—how to not use fellows for the work that must be done to keep the medical center running, but at the same time provide a broad-based education that touches on all of these areas. We need to maintain scholarship with the overarching idea that touching level 1 in a lot of different areas may not be achieving the goal for the individual fellow who may want to be an expert in one area when they leave.

Is Research Mandatory?

Dr Harrington: That is very well said. Many of us who have been involved with training and thinking about training at the national level are recognizing that although this document proposes a new way to look at the training components, we need to have more societally based discussions about exactly how we are going to ensure the competency of our workforce.

You gave the example of scholarly activities, which is a section that I had some responsibility for. We tried to keep the recommendations for training to the kind of scholarly activities that the practitioner ultimately needs to learn if he or she is going to practice successfully independently over time. These are such skills as understanding a journal article, as opposed to thinking about getting down into the weeds of doing a research project.

We all love the idea of fellows doing research projects, but it may not be possible for all of them to do those kinds of projects. It may be that they have to learn some basic skills and that only the group of fellows who see themselves as pursuing scholarly careers will take on these new activities. Otherwise, the time will become prohibitive and it will be progressively more difficult to have people finish the program and be out working in a reasonable timeframe.

We probably also have to do a better job of thinking about the transitions from medical school to residency to fellowship. Does that have to follow such a prescriptive path, or might there be some variation of tracks for different people?

Dr Pinto: True, and one minor thing is, how do you measure whether a fellowship director is doing a good job? It ties into many of the things that we are talking about.

How do you recruit academic talent to be a fellowship director? That requires some finessing of work effort. How do you measure whether that person is doing a good job? Is it compliance in the curriculum with the COCATS requirements? Is it how far they go on the rank list to match people? Is it how many publications the fellows make during the director's tenure or within 5 years, or how many fellows pass the American Board of Internal Medicine (ABIM) test?

These factors are often considered metrics, among many others, but they are also very imperfect metrics that are not necessarily accomplishing the goals of our fellows, who are the primary people we should be worrying about when it comes to fellowship education.

Dr Harrington: How one conducts assessments of physicians, physician leaders, clinicians, clinical teachers, and researchers is another topic. You and I could spend an hour trying to understand methods by which we do that.

Thank you for joining me here on Medscape Cardiology. This has been a free-ranging discussion on some of the issues centered around academic medicine, particularly from the perspective of the trainee and the faculty. We have touched upon some of the faculty recruitment, retention, and training issues. I appreciate your insights.

My guest today has been Dr Duane Pinto, associate professor of medicine at Harvard and director of the Cardiac Care Unit at the BI Deaconess Medical Center.


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