Interventional cardiology has been a rapidly expanding field over the last few years, incorporating more procedures leading to longer training requirements. During general cardiology fellowship, fellows interested in interventional cardiology are facing the challenge of deciding which subspecialty route to follow after coronary training.

An extra year of fellowship in structural interventions is slowly becoming the norm and a single year of coronary training is thought not to be sufficient in the future of evolving complex interventions. Moreover, "plain coronary training" has even started extending into additional years of training.

While it is true that the need for structural interventions is rising with procedures such as transcatheter aortic valve replacement, MitraClip and left atrial appendage closure becoming more popular, most fellows graduating from advanced fellowships are facing significant difficulties landing in academic institutions or even getting a structural job . It is notable that most of the graduates end up in low-volume community hospitals.

Interventional cardiology attracts a pool of competitive applicants with an inherent interest in clinical research and academics. As such, fellows interested in interventional cardiology need to be abreast of these changes and make decisions regarding the length and focus of their training while figuring out the next steps when aiming for an academic career.

Thus, a dilemma arises: pursuing the long fellowship with chances of a short-term abandonment of academic medicine or pursuing the shorter fellowship and missing out on the extra skillset that is becoming more popular.

Graduating fellows often face the challenge of having to make that compromise and find an available structural position, having to move in another state or take a job where they would be limited in coronary procedures but risking losing these hardly acquired skills. With all these recent changes, the big question becomes how much training is enough and for whom.

It has been advocated that training models must adapt to fit in the new requirements and fellows need to participate – if not drive – these decisions. Fellows need to take part in the conversations on designing training paths focused on producing specialists who can use their "specialty skills."

Fellowships need to prepare fellows for the real world and train individuals who will be able to use their skills without compromising their academic contributions. For example, it has been discussed to decrease cardiology training to two years of general fellowship and two years interventional/structural. This change could be a great opportunity which would allow for more focused learning and less financial burden and chronic fatigue from nearly a decade of postgraduate training.

There are many aspects to this issue of training, but it comes down to the individual. A comprehensive assessment of the fellow's career goals is required. If the main focus of one's career is research oriented, the extra year of structural fellowship might result in increased difficulty in securing funding or a position on an academic institution in the near future.

If the focus is mainly on mastering the skillset and maintaining a high volume of structural procedures, fellows need to acknowledge that this might require adjusting to a less academic environment post-fellowship.

This article was authored by Ioanna Katsa, MD, Fellow in Training (FIT) at Montefiore Medical Center in Bronx, NY.