Internists in HF: A Solution to a Lack of Care?

Training internal medicine physicians in heart failure care might be one solution to the current lack of specialists in the United States, a group of advanced heart failure and transplant cardiologists (AHFTC) argue in a new commentary.

“It's a novel solution for a workforce that needs to be bigger but isn't,” lead author Eiran Z. Gorodeski, MD, MPH (University Hospitals Harrington Heart & Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, OH), told TCTMD. “It's another set of physicians who would take care of heart failure patients. So we really would have to expand the tent for them.”

More than half of AHFTC fellowship positions went unfilled in 2022, foreshadowing a pipeline problem that’s concerning as the number of patients with heart failure continues to rise. To meet that gap, leaders in the heart failure last year published a “road map” in the Journal of Cardiac Failure for drawing more interest to the field.

Heart failure fellowships for internists—those who have not completed a 3-year general cardiology fellowships—have been around for decades, albeit with no consistent structure or curriculum.

Earlier this year, in an effort to bridge the gap between the growing number of heart failure patients and the lack of physicians equipped to care for them, the Heart Failure Society of America (HFSA) began allowing internists who have completed one of these programs to sit for the HF-Cert exam.

“Thrilled” with this development, Gorodeski said “this is really the first ever recognition by a national society of any sort that these specialists exist and that they're worthy of getting a certification which they can put on their CV and they can use when they apply for jobs. Hopefully this is going to get the snowball rolling.”

Complementary Care

For their paper, published online last week in JACC: Heart Failure, Gorodeski and colleagues outline the scope of the current problem, drawing particular attention to the mismatch between what is currently taught in AHFTC fellowships and what is needed in clinical practice. They propose the addition of the heart failure internist not as a replacement for those who complete the years of specialty training but rather as a complement to the team, especially in regions currently lacking in heart failure care.

With prior data showing great disparities in care for heart failure patients living in rural regions, for example, Gorodeski said the addition of heart failure internists could help without infringing on what AHFTC specialists are already doing, as some have criticized.

“If you have heart failure in a rural area, . . . your rate of death is much higher than somebody in an urban area simply because you don't have access to care,” he said. “If we can take heart failure internists and sprinkle them in all these rural areas, I think that care will be better. That's not anticompetitive, that's complementary.”

Anybody willing to take care of patients with heart failure is great, because there's not enough of us Eiran Z. Gorodeski

The profile of the HF internist is not one-size-fits all, they authors write. While some who complete this training might go on to do general cardiology training, “graduates from our programs have gone on to become hospitalists, nephrologists, critical care specialists, and geriatricians—all areas in which additional HF expertise is immediately relevant and valuable. In either case, we feel that additional training in HF should be encouraged and validated by professional societies in an effort to increase the workforce of physicians with expertise in HF.”

While standardization of these 1-year programs is necessary, Gorodeski and colleagues highlight several important aspects of any future program:

• Inpatient rounding focusing on treatment of HF exacerbations, the progression to Stage D HF, and cardiac critical care
• Managing patients in a variety of settings including on the floor, ICU, in consultative contexts, and outpatient clinics
• Performing procedures in the cath lab and ICU (primarily right heart catheterizations)
• Elective rotations in multimodality cardiovascular imaging with a focus on echocardiography
• Palliative medicine experience

Many Challenges

The experts say there will be challenges regarding the proliferation of these kind of training programs, acknowledging criticisms that have come from both internal medicine and AHFTC specialists.

The most surmountable of these obstacles are a lack of data regarding how many people have already pursued this pathway and what have they done since, Gorodeski said. However, surveys are underway to address this and, at a minimum, provide a comprehensive list of available programs and what they teach, he added.

A standardized curriculum geared toward noncardiologists is next on the list, the authors say. “Developing such a curriculum would differentiate between HF internist training and ACGME-accredited AHFTC fellowships.”

Since the length of physician training is already criticized as being too long, Gorodeski and colleagues stress that while it won’t be necessary to complete this additional year to care for heart failure patients, “we do believe that the additional expertise will be of great benefit to communities/populations of patients.”

Gorodeski doesn’t think the current training paradigm for internal medicine adequately prepares people to tackle heart failure. “I don't mean to imply that internal medicine doctors in the future won't be able to take care of heart failure patients,” he said. “Sure, they will be able to. All I'm saying is that if some small percent of them decide to do this training, they'll have an even more advanced and sophisticated skill set that will be highly desired.”

Other criticisms have come from his peers in AHFTC, said Gorodeski, noting that some have claimed these programs would “create confusion” for patients. “My response to that is anybody willing to take care of patients with heart failure is great, because there's not enough of us,” he said. “I'm willing to take the small risk of confusion over the possibility of insufficient care.”

Lastly, finding funding for these programs is a challenge, Gorodeski said, given that they are not ACGME accredited. “All of us do struggle with figuring out how to pay the fellowship stipends for these trainees; each one of our systems does it differently, whether it’s philanthropy, whether it's operating funds, whether it's grants,” he explained. “So that’s more difficult to solve, and that needs to be solved at an institution-level locally.”

Gorodeski acknowledged that it’s going to take work to win people over when it comes to this training pathway.  

“Maybe one day in several years we'll get to the point where there's more people who believe in this and are in our camp,” he said. “The sky's the limit because, heck, the rate of growth of patients with heart failure is astronomical. There's not enough of us to take care of them.”