April 13, 2018 | Avnish Tripathi MD, PhD, MPH & Harleen Chahil, MD
Education

The success of transcatheter aortic valve replacement (TAVR) and the fast-paced innovation in percutaneous mitral valve repair have heightened interest in structural interventional cardiology. Consequently, an increasing number of interventional cardiology fellows are pursuing an additional year of training in structural heart disease (SHD). As the coronary interventions are plateauing, or even declining, valvular interventions provide a sense of job security. Regardless of the bright future of structural interventions, many FITs who are committed to sub-specialization in interventional cardiology remain doubtful about the additional year of training. A few of the questions and doubts we have come across include:

- "Structural fellowships are competitive, will I secure a spot?"
- "What will the additional year of training look like?  
- “Will I be able to scrub-in on coronaries and peripherals during my second year?”
- "Is the additional year of training worth it? I have heard getting a structural job is difficult."
- "I am on a J1 visa and will look for a waiver job. Finding an interventional job is tough as is, so will I ever find a structural job?"

Applying for an SHD fellowship starts with knowing your options. Over the recent years, a number of programs offering SHD training has increased, but these spots remain highly competitive. As of December 2017, 149 fellowship programs are listed for interventional cardiology in the U.S. On the contrary, there are only 36 structural training programs, including a few programs that offer a combined two years of interventional and structural training up front. Majority of these programs have limited spots. They do not go through a match and they follow individual timelines, which can vary by more than a year. It is important to contact the program and know what is needed for the application process as well as their timeline. Bear in mind that many programs offer positions on the spot, making it a quick decision for you whether to accept or explore further options.

The Accreditation Council of Graduate Medical Education does not accredit SHD fellowships, meaning they do not follow the same set curriculum. Depending on where you end up, the program may have more exposure to TAVR with less mitral interventions. This is where you will get trained in a dedicated learning environment, so a skewed curriculum will affect your developed skill set. It may also lead to an imbalance in training and potential difficulties when looking for a job.

In addition, there is no number assigned the minimum number of procedures needed for certification. During the structural training year, there is more emphasis on structural procedures, which may lead to decreased use of coronary and peripheral skills. The recognized issues leading the Society for Cardiovascular Angiography and Interventions (SCAI) are to form a SHD council in 2010, focus on developing a curriculum and promote cooperation in the SHD community. This will help in developing mentorship and career development for the trainees. However, colleagues who are currently in or have finished SHD fellowship have mostly assured that despite the inconsistencies in volume for different procedures, an additional year of training in SHD provides adequate foundation skill sets to succeed in practice. They further advise continuing scrubbing in coronaries and peripheral cases whenever possible to help mitigate attrition of those particular skills.

The next step after fellowship is finding a job. Of course, there are the usual things to look out for when interviewing and finding a practice best suited for you. However, as a newly trained structural heart specialist, you may encounter some unique hurdles. SHD is fairly new as a dedicated fellowship program, meaning that in the real world, there are well-seasoned interventionalists who are trained for these procedures and are performing them. The trend of on-the-job training for structural procedures is still ongoing, although there are several avenues of interventional job search and postings (one of the most popular is the SCAI website). At the time of writing this article, there were 20 invasive and interventional cardiology jobs for new graduates, and only one posting specifically required "interventional structural cardiologist." This list is not exhaustive by any means, but still supports the anecdotal account by many colleagues looking for structural jobs that say “there are NO jobs” for international medical graduates (IMG) or U.S. medical graduates (UMG).

The U.S. Department of Agriculture has long recognized the professional shortage of cardiologists in the U.S., especially in underserved areas. With 40 percent of cardiology training positions currently filled by IMGs and 25 percent of the practicing cardiologist in the U.S. being IMGs, they help mitigate the keen shortage of cardiologists in the U.S. However, the vast majority of IMGs in cardiology fellowships are on a J-1 visa, which presents unique challenges. After completion of training, if a fresh J-1 graduate wants to remain in the U.S., they have to obtain a J-1 waiver position through the Conrad 30 program. Only 25 percent of the positions may go to the specialties, whereas 75 percent go to primary care physicians. In addition, each state has limited positions for cardiology sub-specialties and the application process for these positions usually starts more than a year in advance. The IMG fellows who are interested in SHD should be aware of these challenges of job-searching. That being said, from the compensation standpoint, there should legally be no difference in wages and benefits between IMGs and UMGs.

Every cardiology fellow has a quintessentially important decision of whether to join academia or private practice after graduation. Despite the well-known differences in compensation and time commitments, the decision between the two essentially depends on one's own passion and interest. However, one question that applies to both tracks is whether the extra year of training in SHD helps secure higher compensation. There is not much available in terms of literature on this topic, but after speaking with several senior operators in both academia and private practice, it appears the extra year of training may not add to upfront increments in starting compensation. Several senior operators alluded to the fact that complex procedures, including structural procedures, tend to decrease reimbursement and productivity in the current relative value units model system. Anecdotally, one of the senior operators suggested that complex and time intensive procedures, including TAVR and mitral clip procedures, may lead to a negative impact on yearly compensation by about 20 percent.

Despite the challenges and hurdles, everyone eventually finds the position that suits their interest best. SHD is a new and exciting field of cardiology, and the increased number of endovascular procedures makes it a popular and exhilarating option for fellows. When applying and exploring your options in this field, it is important to keep these points in mind so you can make informed decisions regarding your career. With the increasing interest and the recognition by SCAI, fellowships will become more structured and will allow for more information for prospective fellows. In the meantime, it is important to keep an ongoing dialogue between current fellows, experts in the field and prospective fellows.

This article was authored by Avnish Tripathi MD, PhD, MPH, Fellow in Training (FIT) at the University of Louisville Medical School, and Harleen Chahil, MD, cardiologist at Frankfort Regional Medical Center in Frankfort, KY.