Cardio (Interventional) competitiveness

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filmdoc26

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I know that the cardio subject has been beaten to death. But I can't seem to find any information on numbers such as acceptance rates into cardio fellowships (specifically interventional). Is it that much harder than others? Also...is research a necessity for this field? Thanks!

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filmdoc;

Cardiology remains one of the most if not the most competitive subspecialties in internal medicine (GI also being very competitive). Specifically, interventional fellowship is started after finishing general cardiology fellowship. And this field is extremely competitive amongst cardiolgy fellows.

In our program, a smaller, university-based program, we have over 500 applications for 3 postitions this year. We're interviewing 40 applicants. Granted, most of those 500 applicants applied to several other programs, so I don't know the number of the actual applicant pool. A good rule-of-thumb is to apply to several programs from high-tier to lower programs and interview at ~10 programs... That way the odds are in your favor to match as most program interview ~10 applicants per position offered.

Some basic advice if your goal is cardiology: go to a good IM program (not a community-based program), start doing some research (preferably CV) as an intern (or med student) with the goal of publication (manuscript>abstract>poster presentation), get great letters of recommendation (this is prob'ly the single most important step because everyone has great stats... letters tend to set the applicants apart. A mediocre letter will kill your application and a good letter isn't good enough, it has to be glowing: i.e.: stuff like "we'd love to have Fred in our program", "he's the single best resident we've had in our program since the beginning of time...", "he's the son I never had...", believe it or not, people actually write this stuff. Attendings who know how to write a good letter know this stuff and will sing your praises: finding the right person is the hard part so ask upper level residents at your program who to get letters from... All the residents at our program know who to solicit letters from and who to avoid.) Lastly, board scores are important as a 'weed-out' tool but won't get you an interview but could get your application round-filed...

Go luck!
 
You won't find stats posted on interventional spots because the # of spots vary from year to year, and many spots are "unannounced" or created out of thin-air, so to speak because of how spots are funded.

Most positions are funded thru the federal government, and as such, are subject to the same disclosure rules that federally funded residency positions are. So if you get on Frieda, for example, you'll see a ballpark # of spots. But there are a number of spots funded thru grants, thru a private practice affiliated with a particular Cards fellowship program, or thru some other source, that aren't disclosed. These spots may be given to people whom a particular program wants to keep on for Intervention, or to other favorite people from elsewhere. They may have only one funded spot like this every couple of years or so, but you get the point.

Some things to consider about intervention/interventional spots:

1. Competition isn't what is used to be. The Cardiology job market is looking for more non-invasive/invasive Cardiologists than interventional ones. In the most unscientific method possible, look at the Cards job offers in the back of the NEJM, and compare how many offers for non-invasive/invasive there are compared to intervention. In private practice, at least, the demand for intervention is good, but not as brisk or robust as the others I've mentioned above. One caveat is academic interventional spots, where they can't get enough people. But as a result, getting interventional spots isn't as tough as it was before.

2. There are a mix of 1 and 2 year interventional spots. 2 year spots give you a better mix of coronary and peripheral intervention, although I've heard many places are now able to give you adequate training in both in 1 year. I don't know if this amount of time is adequate to do both, so may be worth asking others in the know.

3. Interventional Cardiology doesn't pay as well as it used to. I have a good friend who just finished fellowship at the Cleveland Clinic and was offered an interventional spot there which he subsequently turned down. He ended up joining a private group in Indy. His reasons for not doing intervention include a comparatively worse lifestyle in intervention, since most avg sized groups only have 4 or 5 interventionalists. But more than that (which matters once out of training) is that the $$$ in intervention is not what it used to be. 2-3 years ago, a 2v PTCA with stenting paid $2-3k. Today, it pays $700-800. With all the same overhead, malpractice, and other fixed costs, you do the math. Now if your passion is to balloon arteries open, then do what you need to do, but this is definitely food for thought.

4. What does pay well (soon to be the most, from what I understand) is imaging and nuclear -- TTE, TEE, DSE, AdThal, MUGAs, other nuclear studies, and sooner rather than later coronary CT/MRI. The latter will eventually supplant diagnostic catheterization. So what will eventually happen is that the only people getting cath'd are those for whom a percutaneous intervention is planned.

RTK gives some great advice for positioning yourself for fellowship.

Good luck!

:)
 
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Task,

Do you think radiology will do the CT/MRI or will cardiology?
 
you may be exaggerating the impact of mri on cardiac catheterization. unless you are talking about a really lengthy time frame. certainly as technology continues to improve, the problems associated with the mri will be solved, but presently no mr specialist i know even pretends to be able to grade the stenoses they see. so right now, it will certainly have an adjunctive role as the sensitivity is reportedly tremendous in screening for cad, but not necessarily relegating the role of cath to pre-intervention.
and certainly there are enormous financial and political forces who would stand in the way of such development.
 
I think that cardiologists will control the imaging in many places.

1. Many radiologists are not interested in learning a whole new branch of pathology
2. Cardiologists control the patients
3. Cardiologists are generally much more aggresive

Because of the radiologist shortage many groups can negotiate with hospital administrators. Ok, we dont do Cardiac MR, fine. We will open an outpatient center two blocks from here and do what we want. So find another group to replace us. The administrators may quickly come to their senses.
 
Wow...Fantastic responses! Thanks so much, rtk and task!

Considering the widespread heart problems America has and the population boost of elderly underway with the coming of the baby boomers, I hear that cardiologists are and will be high in demand. Correct me if I'm wrong, but shouldn't the medical field respond by creating more fellowship opportunities? Or is the demand met by creating more jobs post-fellowship?

Even better, what does an IM resident do if s/he can't get into a general cardio fellowship? Apply for another specialty the following year?
 
If you don't match the first time, re-apply.

That's what's happening with folks who don't match in GI or Cards, which have become two of the most competitive subspecialties out of IM. There are varying opinions as to which one is more competitive -- GI has way fewer spots than Cards, but there are more people applying to Cards (until the last 3 years, that is -- #s of GI applicants have ramped up tremendously). Either way, to match in one or the another is commendable, and puts you in a privileged group, to say the least. The ones I know of who don't match the first time usually have success the second time (at least in Cards). There are a few people I know who didn't match GI two times running -- one is doing IM, and one finished IM and is now doing Anesthesia residency as a "fellowship".

I bring up the competition stuff only to address your other comment to the effect of why aren't there more fellowship spots and why doesn't the market dictate the #s. It is precisely the market that is dictating why the # of spots are where they are. Cards and GI fellowship programs are producing a commodity, and it is to their advantage to make that commodity worth as much as possible -- they then can attract the best and the brightest, so to speak. 5-7 years ago no one would go into GI. Then they got all these cool new procedures that paid really well, and Medicare/Medicaid started paying for them (especially colons), and you have to beat away the applicants. Why increase the # of fellowship spots when the numbers trained now create just enough of a shortage that there is huge demand. The same for Cards -- there was an article about 6 mos ago on theheart.org about changing the training requirements for Cards due to the long training period, so there could be more produced to meet the demand. The article was hilarious because it discussed all these recommendations being made by various big-wigs in the field, then right after the article there was a commend by (I think) one of the leaders in the ACC who basically said "we're not changing anything".

Basically, it's not in the interest in any field that's "in demand" to try and keep in equilibrium with the demand. It's most advantageous to keep demand healthy so that you attract good candidates, and so that when a downswing (which happens with every field) occurs in that field in terms of demand and popularity, the people in that field aren't hurting for jobs.

Unfortunately, it's not altruistic intentions that hold complete sway over these types of decisions.

Here are some other examples:

Rads -- oversupplied for years. Then all sorts of new technologies in Radiology, and not enough people to do all of them, so now a huge demand. Rads programs actually did increase the # of spots, but that is hugely rare.

Anesthesia -- same as above -- needed a bunch more. No increase in spots.

Ophtho -- actually kept turning out more trainees than needed, and now, way oversupplied no matter who you talk to.

ENT and GU -- have always kept their #s low so they are always in demand.

I agree with the above poster as to who will control cardiac imaging -- Cardiologists, precisely because they are so aggressive and control the patients. I already know of groups who are planning to acquire MRI machines, and many fellowships already incorporate training with this modality as well.

smackdaddy -- good point. I'm not talking about the next 5 years. But as the imaging and the processing power of these machines becomes better, say next 15 years or so, then I think you will have imaging good enough to grade lesions in vessels of all caliber. The most well known study to date was that about MR one in the NEJ about a year or so ago which only had a 70% sensitivity for LM or 3vd, which is terrible, but will get better.
 
i actually had dinner the other night with one of the fathers of cardiac mr. he assures me with their current machines and reading have a sensitivity of 100% over the past couple years. specificity is around 40-50%.
of course, it's all in who is doing the interpretation.
btw, he trained the guys who did the nej article.

his interpretation is that they are going to have to show definitively that mri is as good as cath, and that acquiring the data will take many years, once the technology is mature. and if hospitals already have pet scanners and nuclear scanners, the likelihood of acquiring a dedicated cardiac mr machine will be low for years beyond that. certainly there may be some local early adapters of the technology, but i'm not sure it is required training at this point. in any case, it probably wouldn't be for interventionalists.

on an unrelated note, my parents live in a pretty affluent area. everyone pays cash for most medical procedures, and gets reimbursed later. a couple years ago, my mother lost vision in one eye and called around to the three ophthalmologists in the town. despite the acuity and serious nature, they all told her one month to the nearest appointment. so oversupply is relative. those three guys are there raking money in and just block privileges for other ophthalmologists who could do the work, but would take money away from the guys already there.
 
As you mentioned, the main problem will be in who is interpreting the images. I merely only quote the results from the NEJ article that I recall.

As with other modalities, I think it will be larger, well funded or backed groups that begin to use the technology and "force" the issue, so to speak, for good studies to validate practice patterns and algorithms. What I mean to say is, I think the proliferation of cardiac MR (regardless of how good the technology is) will be spearheaded by large private groups of "heart physicians" -- these conglomerations of cardiologists and CVTS people in practice together that have the $$$. All these people will be getting scans at the behest of their cardiologist, and then you have an image of "apparently" significant CAD in an asymptomatic patient. At that point, one could always make a case (playing devil's advocate here) that that person needs to have further risk stratifiction or needs to be taken for revascularization.

I'm not sure where your parents live, but I'm sure their situation is not unusual with regards to Ophthalmologists. Those three guys in practice together have a nice gig going, probably because they're so well established. But I'm sure your mom could go the next town over and have no trouble finding someone (in an urban area) to treat her. There are still many places in the country where Ophtho people make a good living. But in most places, it is tough. Ophtho is one field which consistently, year after year, finds reimbursement for its procedures being reduced, by greater percentages than in other procedural fields.

Many people in Ophthalmology residency/fellowship I know are really surprised/disappointed in the kind of offers/location of offers. Either the money is way below what they expected (and this isn't the generation expecting to make a million a year doing cataracts -- they're getting $90-110k starting for an urban area, maybe $120-130k rural), or they have to move to BFE to make enough $$ to pay off all their debt. The general consensus I glean from them is that rural>urban (true for most fields), but that the discrepancy is much more severe than for other fields. I live in Dallas, and a retina fellow I talked to said that the retina guys here are climbing all over each other for cases. I use retina because it is apparently one of the most competitive and highest paying subs. in the field. From what I've been told, forget the coasts and the larger cities in the midsection of the US. The $$ and jobs in Ophtho are in the smaller cities/rural areas.

Sorry, a little (lot) off topic
:)
 
One other thing.....

I'm pretty sure that cardiac MRI training is not required in Cardiology fellowship programs. But, if a program was trying to sell itself to prospective candidates "we teach you all forms of imaging, including MRI...." then I definitely think that would be a selling point in the program's favor.
 
I think it's premature to say that in a hospital setting that the cardiologists will be the ones reading the cardiac mri. In an outpatient setting I think the one could argue more strongly for cardiology practices to take more of the work away. In any case, I think there there may be self-referral issues and accrediting issues to work around. Some of the Stark laws may get more stringent when the government figures out how much more it's going to cost the system to have cardiologists self-refer ($) themselves MRI imaging.

It's really a detriment to the healthcare system to have self-referring imaging, but that's not stopping most physicians.

I have heard that some vascular surgeons working as a group with IRs now and the income for both vascular surgeons and IR groups have increased relative to what they were making separately. So it may not be so far fetched that this could happen cardiology. It may turn out that working with cardiologists may be better than competing against them. In any case, it will be interesting to see how it all turns out.
 
13 year bump. Nice. Well 13 years later both cards and rads are doing cardiac imaging in the academic setting. This is often shared or read by both groups with multidisciplinary meetings as places to learn from each other. 13 years later, imaging technical fees have dropted dramatically and new laws are in place. It is no longer feasible for a private practice cardiology group to tell a hospital that they will open up an outpatient mri center down the street if not given hospital privileges to do MRI. This will remain academic for the time being a probaby a shared modality or within Radiology in the long term (esp CT in such as triple rule out).
 
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