Training Directors Symposium

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Training Directors Symposium

• ACC-FIT Committee Work Group on Training Program
  Initiatives

Jeffrey L. Williams, MD MS Grace Chen, MD
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Introduction

• A recent survey of cardiology fellows indicated
  at least a quarter of respondents would like to
  see fast-track training programs in such
  subspecialties as electrophysiology or
  interventional cardiology.
• The 35th Bethesda Conference (JACC, V. 44, No. 2,
  2004) predicted an impending shortage of general
  cardiologists.
• The 8th Working Group suggested a means to allow
  a 5 year short-track to train general
  cardiologists. However, they did not discuss the
  possibility of fast-tracking for Interventional
  or Electrophysiology Fellowships for those who
  have already completed a 3 year Internal Medicine
  residency.
• Fast-tracking would comprise 2 years of a
  General Cardiology Fellowship then 2 years of
  either Interventional or Electrophysiology
  training.

ACC FIT Committee March 2006
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Demographics of Respondents

• Number of Surveys Sent Total386
• General Program Director183
• Interventional Program Director121
• Electrophysiology Program Director82
• Number of Surveys Returned 191/386 49.5
• What type of Program Director are you?
• General Program Director 89/191 46.6
• General and Interventional 6/191 3.1
• Interventional 57/191 29.8
• General and EP 6/191 3.1
• EP 33/191 17.4

ACC FIT Committee March 2006
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Duration of Training Programs Fellows from Within

• What proportion of your fellows (over the past 3
  years) completed their general cardiology
  training at your institution? 61.6
• For your EP/Interventional fellows completing
  their general cardiology fellowship at your
  institution, how long is their training? (Answers
  by General Program Directors included in these
  numbers)
• 2 Years of General Cardiology and 1 year of
  EP/Interventional 1/1140.9
• 2 Years of General Cardiology and 2 years of
  EP/Interventional 14/11412.3
• 3 Years of General Cardiology and 1 year of
  EP/Interventional 76/11466.7
• 3 Years of General Cardiology and 2 years of
  EP/Interventional 17/11414.9
• Other (please explain) 6/1145.2 (This was
  explained by requiring EP to do an additional 2
  years and Interventional only 1 year)
•  
• Note 21 of programs fall outside the ACGME
  Accredited Program Guidelines for training.

ACC FIT Committee March 2006
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Duration of Training Programs Outside Fellows

• For your EP/Interventional fellows completing
  their general cardiology fellowship at another
  institution, how long is their training?
• One year of EP/Interventional 73/10768.2
• Two years of EP/Interventional 30/10728
• Other (please explain) 4/1073.8

Note 31.8 of programs fall outside the ACGME
Accredited Program Guidelines for training when
taking fellows from outside their institution.
There were numerous suggestions to require a
two-year EP fellowship but only a one-year
Interventional Fellowship. These were denoted as
1.5 in the spreadsheet as the Duration of
Training. Some programs required an elective
research year.
ACC FIT Committee March 2006
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Is one year of an EP or Interventional fellowship
adequate experience to perform advanced EP or
Interventional procedures?

• Yes (73/17841) or No (105/17859)

ACC FIT Committee March 2006
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Are you in favor of developing a means to allow
fellows to fast-track?

• Yes (120/18963.5) or No (69/18936.5)

ACC FIT Committee March 2006
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General Comments from Program Directors

• This survey is an Excellent approach for the
  needs of trainees.
• Fast-Tracking would favorably impact all
  programs I would strongly support this.
  Fast-Tracking also would increase women
  candidates.
• Fast-tracking is not an appropriate proposal. It
  takes time and experience to become mature enough
  to thoughtfully render these services. We must
  not allow a few trainees eagerness to get to the
  big bucks to drive training policies. Well end
  up producing a lot of hacks and crappy doctors.
• What if a fellow decides he no longer wants to do
  Fast-Track part way through his training?
• What evidence is there for needing a fast track?

ACC FIT Committee March 2006
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Modeling Numbers of Cardiologists Through 2020

• A. Number of EP and Interventional Spots per
  Year The 35th Bethesda Conference, revealed
  that only 120 of 173 EP spots and 229 of 269
  Interventional spots are filled per year.1 Thus,
  these numbers were used throughout the
  calculations.
• B.  Total Cardiovascular Trainees From 2001,
  there were 2160 total trainees and 709 first year
  fellows.1 Average number first-year fellows
  since 1995 is 717.
• C.  Total General Cardiologists In 2005, there
  were an estimated 6 cardiologists per 100,000.2
  This was used as a basis for calculating the
  number of cardiologists in the US at 16800.
• D. Growth in Need for General Cardiologists2
  Estimated at 5.3/year.
• 1.  Effect of Retirement It is estimated that
  10 of Cardiologists will retire within the next
  decade. Thus, the model uses 1/year increase in
  need due to retirement.
• 2.  Effect of Growing Prevalence of CAD Until
  2030, the prevalence of CAD will grow by
  2.3/year. The model uses 2.3/year increase in
  need due to increasing prevalence of CAD. After
  2030, the prevalence of CAD is adjusted to
  reflect the aging Baby Boomer population.
• 3.  Effect of Decreasing Patient Load The
  average physicians patient load in
  cardiovascular medicine declined by over a third
  from 1980-1995. For every 10 decrease in
  average patient load, 20 more physicians are
  required. The model uses 2/year increase in
  demand due to decreasing physician patient load.

ACC FIT Committee March 2006
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Projection of Number of General Cardiologists
from 2005-2020
ACC FIT Committee March 2006
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Effect of Filling 100 of EP and Interventional
Fellowship Spots Starting in 2006
In 2001, only 120/173 (69) of EP Fellowship
positions and 229/269 (85) of Interventional
Fellowship positions are filled. A 100 fill
rate, using todays training duration, would lead
to a 6.2 decrease in General Cardiologists
(n1395). Fast-Tracking would help to offset
this decrease.
ACC FIT Committee March 2006
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Effect of Doubling Number of General Cardiology
Fellows
ACC FIT Committee March 2006
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Projections of Cardiology Workforce Until 2050
Incorporating Loss of Baby-Boomers.
What if this model is correct? The public did not
tolerate restricted access to subspecialists in
the 1990s.
This model incorporates a decrease in CAD
prevalence by 0.06/year from 2030-2040 and
0.05/year from 2040-2050. Current training and
Fast-Track would still result in deficit.
ACC FIT Committee March 2006
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Summary of Fast-Tracking Based Upon Model

• Fast-Tracking will increase the number of General
  Cardiologists output.
• Assuming no change in number of total General
  Cardiology fellows allowed, Fast-Tracking will
  help reduce the predicted shortage in 2020 by
  adding 1396 General Cardiologists by 2020.
• Fast-Tracking, while streamlining the training of
  EP and Interventional Cardiologists, would allow
  a 2 year dedicated time-frame for training in the
  specific sub-specialty.
• Fast-Tracking will not increase the total number
  of EP or Interventionalists.

ACC FIT Committee March 2006
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Weaknesses of Model

• A.  This model assumes that it is possible to
  have varying number of fellows per year in a
  training program.
• B.  This model assumes that there is a certain
  amount of GME training money available in 3 year
  aliquots. This is required because number of
  fellows per year is not constant.
• C.  Additional revenue stream is needed to fund
  the 2 year EP and Interventional Fellowship.
• D. What happens if fellows change their minds?
• E. What happens to fellow workforce in smaller
  programs?