Heart Failure Care Has a Pipeline Problem: What’s the Fix?
Advanced HF and transplant cardiology fellowships are going unfilled, while general cardiology skirts basic HF care, experts say.
Heart failure experts are warning that despite seeing some of cardiology’s most exciting therapeutic advances over the last decade, their field has a serious pipeline problem. Unless steps are taken to revise training programs, they say, there won’t be enough specialists to care for the fastest-growing patient population in cardiology.
According to numbers published by the National Resident Matching Program (NRMP), of the 70 US fellowship programs offering 121 positions in advanced heart failure and transplant cardiology (AHFTC) fellowships, 40% of programs and 52% of positions went unfilled in 2022, continuing a trend also seen in years prior.
And while many have theories to explain the disconnect, physicians say there’s an urgent need to rethink training programs, as well as when and how the heart failure curriculum is taught.
“The trajectory that we're on is that there won't be enough heart failure expertise in the community to take care of this massive wave of heart failure that's coming,” Eiran Gorodeski, MD, MPH (Harrington Heart & Vascular Institute, University Hospitals Cleveland, Ohio), told TCTMD. “As somebody who thinks about clinical care and public health, I think that's very worrisome.”
Andrew Sauer, MD (Saint Luke's Mid America Heart Institute, Kansas City, MO), agreed.
“We have a burden of heart failure that's growing to 8 million by 2030, and we have a pretty stagnant specialty board-certified advanced heart failure/transplant cardiology pool,” he said. “That means there's going be 8,000 heart failure patients for every one heart failure specialist if things stay this way over the next 8 years. And that’s a scary ratio.”
Specializing in Advanced Heart Failure/Transplant
Part of the problem is how heart failure fellowships were created and structured.
Vanessa Blumer, MD, is currently doing her AHFTC fellowship at the Cleveland Clinic Foundation in Ohio. Back when the AHFTC subspecialty was created in 2008 (with formal acknowledgement from the Accreditation Council for Graduate Medical Education [ACGME] 5 years later), the thinking was that internal medicine training was enough to “take care of” the general heart failure population, although heart failure curricula would also be included in the general cardiovascular disease fellowship.
Where board certification was warranted was in the specialized treatment of patients requiring transplantation or left ventricular assist devices (LVADs), she said.
I think that the trajectory that we're on is that there won't be enough heart failure expertise in the community to take care of this massive wave of heart failure that's coming. Eiran Gorodeski
“We're now a decade later and obviously heart failure looks very different today, and I think that's what people are appealed by, right? Our patients are highly complex, there's a wide range of pathology, and we now have tons of diagnostic and therapeutic advances in the field that are ultimately breathtaking,” she said.
She continued: “I think some trainees might be dissuaded from pursuing advanced heart failure and transplant cardiology because their interests do not lie precisely in heart transplantation and LVAD management, but maybe in other aspects of heart failure care that are equally unique, and special, and great, but those are not perceived as needing to be prioritized under the current training model.”
“The current advanced heart failure/transplant cardiology training pathway is relatively outdated,” agreed Anu Lala, MD (Icahn School of Medicine at Mount Sinai, New York, NY), who lead’s Mount Sinai’s AHFTC fellowship program. “LVAD and transplant is really the tip of the iceberg when you think about patients who are living with heart failure, and heart failure now encompasses more disease processes than ever before, ranging from medical therapy for heart failure across the spectrum of ejection fraction, all the way to percutaneous valve therapies. . . . We've never had such a broad umbrella before, so I think we need to make the training pathway correlate with what is actually involved in heart failure care.”
Complicating that scenario is the fact that for fellows who do the required 3-year general cardiology fellowship followed by the 12-month AHFTC fellowship, there may not be a job for them when they finish, said Sauer. This stems from the fact that some centers may be offering more training spots than the cardiac transplantation and VAD volumes warrant, raising the potential for fellows to emerge without adequate exposure. Other centers that don’t have transplant/VAD programs may be looking to hire AHFTC graduates to lead heart failure programs but these, without the procedural aspects fellows trained for, may hold little appeal.
There’s also the problem with how heart failure specialists are compensated, added Sauer. “I always say, follow the money,” he said. “An advanced heart failure/transplant cardiologist generally makes less than their general cardiology colleagues,” despite an extra year of training, because the role entails a lot of “attending,” not too dissimilar from a hospitalist or intensivist.
“The pay per RVU for heart failure is higher, but the overall ability to produce in an RVU world is much lower when you're not doing procedures, you're not reading echos, you're not doing imaging studies, you're not doing multiple days of transesophageal ECMO, or cath, or EP interventions,” Sauer said. “In a world that is pay for performance and fee for service, we have a very biased system that will incentivize cardiologists to do the other things and not do the stuff that the heart failure population requires.”
Lastly, he added, if the only heart failure fellows are exposed to involves patients with the most-severe disease, they may not get a full sense of the rewards seen in ambulatory and inpatient care.
Burnout is real for advanced heart failure specialists whose work is so focused on what are often terminally ill patients, Sauer said.
“You definitely never really get a break from the disease, and the disease is huge. These are really sick people, the most-complex people we care for in the cardiovascular space. So if you're a fellow and you see your mentors just kind of burning out, running around seeing patients in the ICU and on the floor 13 weeks a year and 13 weekends, and you don't get to see them be with their families, and you don't get to see them having success in the clinic and seeing their patients get better—because the only time you see heart failure or transplant is these really messy, complex complications in the ICU—that is not going to incentivize you to go into that field.”
General Cardiology Deficits
Another reason for the pipeline problem is the quality and intensity of the heart failure training within the general cardiovascular disease fellowship. As Gorodeski pointed out in the NRMP data, nearly all general cardiovascular fellowships were filled in 2022, but fully 502 applicants never matched, yielding a ratio of 1.5 fellows per available position.
For those who do match for general cardiology, the amount of advanced heart failure exposure they get is highly variable, he continued. Depending on where they do their fellowships, many trainees may never get exposed to advanced heart failure, VADs, and transplantation that would inspire them to seek out another year of specialized training.
According to everyone interviewed by TCTMD, however, even the amount of ambulatory and inpatient heart failure care in the general cardiology curriculum is inadequate for today’s field. The American College of Cardiology’s Core Cardiovascular Training Statement (COCATS) 4 specifies that fellows in general cardiology spend a minimum of 2 months on heart failure rotation, but that’s not set in stone.
Earlier this month, Lala posted a Twitter poll asking fellows and attendings how many weeks of heart failure their general cardiology fellowship required. Just one-quarter said they required 12 weeks or more, 33% said 8 weeks, and 31% said only 4 weeks were required over the entire 3-year program.
🚨RESULTS ARE IN— Anu Lala-Trindade (@dranulala) December 8, 2022
280 votes - 8 weeks was the “winner” at 33% but 31% with 4 weeks (or less!? 🤯)
Do you think we would 👀 this degree of variability in Cath? Nuclear? Echo? CCU?
🤔 It is time to ensure ⬆️ consistent exposure to #FunctionNotFailure in general🫀fellowship. #ACCFIT pic.twitter.com/lvErZ28j83
“I was shocked to see how variable it is for people training in heart failure,” Lala said. “When you’ve got that degree of variability, which I suspect you won't see in other areas, like nuclear medicine or stress testing or echo or cath, then you know the variability is also going to contribute to the variability of the pool of applicants.”
That experience is not unique to the US. Earlier this year, Aws Almufleh, MBBS, MPH (Queen’s University, Kingston, Canada), and colleagues surveyed all 15 cardiology residency programs in Canada to find out about exposure to ambulatory HF management, publishing their findings in the Canadian Journal of Cardiology (CJC). They learned that only 60% of programs required three or more ambulatory HF rotations and less than half offered at least moderate exposure to ambulatory, nontransplant HF patients.
Those numbers, write Almufleh and colleagues, are in keeping with US programs where ACGME allocates less than 20% of cardiology residency training to the ambulatory experience.
Of note, most survey respondents agreed that adopting a new curriculum that focuses on practical and experiential aspects of guideline-directed medical therapy (GDMT) optimization was a good idea, with 87% of respondents agreeing that a GDMT optimization module was warranted, and 93% agreeing that their programs were structured in a way amenable to such changes.
General cardiology fellowships were designed decades ago, said Justin Ezekowitz, MBBCh (University of Alberta, Edmonton, Canada), senior author on the CJC paper, and they haven’t necessarily adapted to modern-day use of technology.
“I think the persons building the programs really need to look at the programs to make sure that [fellows] are getting the appropriate coverage for things that matter these days. We now have AI reading our ECGs—how much do people really need to understand how to read a normal ECG? So they can probably just truncate that a lot. And how many people are really going to use their CT coronary calcium score training?”
More Than Just Meds
Blumer had other ideas for rethinking general cardiovascular fellowship curricula.
“I think there needs to be a standardization of heart failure exposure within cardiovascular training, and this actually needs to showcase more clearly the heterogeneous aspects of heart failure care, which includes outpatient heart failure management, inpatient care of heart failure patients, critical care management of heart failure patients, interventions performed within heart failure, and more cath lab experience geared towards heart failure patients,” she said. “If you don't showcase this within the cardiovascular disease training program, it's very hard to guarantee a [heart failure] pipeline.”
I think heart failure cardiologists have proven time and time again to actually do those things to a greater extent than our general cardiology colleagues. Andrew Sauer
Sauer, too, stressed the need for cardiology fellows to be exposed to all the ways that heart failure specialization offers the opportunity for “intersections” with other subspecialties, not only interventional cardiology, but also structural interventions, electrophysiology, congenital heart disease, and cardio-oncology, to name a few. “All of these spaces are really not going to be well served if we don't have some alternative heart failure training or some change in heart failure training that better incorporates those roles,” he said.
Perhaps the biggest argument for changes to general cardiology training is in the fact that study after study has shown that non-heart failure specialists are doing a dismal job getting patients swiftly optimized on GDMT.
“Cardiologists as a subspecialty are actually failing to implement our guideline-based therapies and inertia is a very, very real problem,” Sauer said. “[Cardiologists] are incentivized to do lots of procedures and do lots of tests; we are not incentivized to apply the heart failure guidelines, unfortunately.”
When people argue that there isn’t a need to train more HF cardiologists, Sauer points out that it’s these specialists who’ve proven that they’ll provide better care, including the prescription of GDMT, than their general cardiology colleagues.
What’s the Fix?
A range of options are being explored for ensuring that the pipeline of heart failure specialists doesn’t splutter to a drip. According to Lala, “there are multiple conversations happening between the Heart Failure Society of America [HFSA] and the American College of Cardiology, as well as within our community, which is so vibrant and so invested in ensuring that the pipeline is strong.”
Some are looking at the AHFTC fellowship with an eye to enriching the curriculum to include the kinds of “intersections” Sauer listed, offering fellows a role in device-based heart failure interventions and heart teams’ discussions.
It is not only a missed opportunity to recruit interested individuals into this fascinating field, but I think, more importantly, it's a missed opportunity to better care for our patients. Vanessa Blumer
Others believe board accreditation in heart failure should include clinic rotations and community outreach to better optimize the use of proven medical therapies so underutilized in patients who might, with better management, never find themselves needing a VAD or a transplant.
Several people spoke of the growing interest in creating a dual certification in critical care medicine and advanced heart failure, which by offering a wider scope might be more alluring to would-be fellows.
Everyone agrees that rethinking the general cardiovascular fellowship to include more heart failure pharmacy immersion and clinic time is also essential. One idea raised by several clinicians was to condense the general cardiovascular disease fellowship to 2 years, with the third year focused on heart failure or other areas of training not currently covered by subspecialty fellowships.
There’s also the potential to innovate even earlier in the training pathway, suggested Gorodeski, pointing to the 31% of internal medicine graduates who weren’t matched for general cardiology in this year’s cycle. Many of these, he noted, are international medical graduates.
“This is a group of very talented physicians who are, in my opinion, kind of ignored, and I wonder if part of the solution could be to come up with an innovative out-of-the-box approach to give this workforce training to become heart failure doctors.” Not advanced HF/transplant doctors, he clarified, but rather community- and clinic-based heart failure physicians, who complete a 1-year heart failure specialization directly out of their internal medicine residencies.
It’s a controversial notion, he acknowledged; many critics would say that these physicians “haven’t passed through the gateway of general cardiology.” But in his mind, these are physicians eager to work in cardiology who are being turned away, despite a dire need for more specialized heart failure care.
To this end, his hospital has pioneered a 1-year nonaccredited fellowship program for internal medicine graduates. Other academic centers in the United States have created similar programs or have reached out to him to learn more. “I would love to see a future where we can envision really formalizing this and maybe even getting accreditation, because why not create a new kind of hybrid internal medicine/heart failure-trained individuals who are recognized and respected and can shoulder the burden of the care for this population?”
Lala suggested, as a first step, having better data: surveying cardiology fellows to find out their primary interests and what factors play into their decisions on subspecialty training—an HFSA task force is already planning to do this, she noted.
Also needed, she continued, is a survey of the approximately 1,400 practicing heart failure clinicians to understand what they find fulfilling and what they see as gaps or frustrations in the field. Doing so would “provide a more-accurate feel as to what the current climate is for having a job in in this subspecialty,” said Lala.
More aspirational goals include the long-running battle to change reimbursement models that would make heart failure more attractive to trainees. Sauer suggests starting with the “intersection points” between societies, payors, and the US Centers for Medicare & Medicaid Services (CMS). For example, the CMS could mandate a heart failure specialist in heart team discussions for a patient being considered for a transcatheter edge-to-edge mitral repair procedure as a prerequisite for reimbursement, much the same way two-surgeon sign-off was required for early TAVI procedures.
“I think you have to begin with . . . the people who control the incentives,” Sauer said. “If we want people to take care of these complex, many of them geriatric heart failure patients, then we are going to have to do a better job incentivizing what happens in clinic.”
Change, on multiple fronts, is urgently needed, say all of the heart failure physicians interviewed by TCTMD.
“I think that the time to act is now,” said Blumer. “If we don't, it is not only a missed opportunity to recruit interested individuals into this fascinating field, but I think, more importantly, it's a missed opportunity to better care for our patients. The contemporary heart failure patient is very complex with a high disease burden, and we need to match our training to the patient population we are caring for.”
Hopefully, said Sauer, more people will move from rehashing the problems to solving them.
“I wish I could understand more what the solutions would be, but hopefully this will get people thinking about it,” said Sauer. “Unfortunately it’s a bit politically charged, but we’ve got to do something. . . . People are tired of watching this trend and they're scared. We’re scared for the future of our patients.”