That's fantastic, Dr. Pham. It's so great to have your perspective, because I think this is all about what it means to be a trainee and how you then progress from being a trainee to being an independent practitioner. So super important to have that perspective. So I think it's been an incredibly fruitful discussion and we've heard a lot about the document. You know, as a fellowship program director, I want to know how does the rubber meet the road? How are we going to bring this to life and how are we going to implement it? We have a wonderful panel here tonight. There've been some great questions that have been asked. So I just want to open it up now so there can be discussion. One of the things that was raised was, say you want to train in all three, can you do that? I was impressed as I heard the descriptions. It's almost like a la carte. Say I do 50 TAVR, but I don't do any MitraClips. I'm not exactly a structural full-on, like one-year structural trained cardiologist, but maybe I'm a person who does some TAVR. Maybe I've done enough peripheral interventions in one particular field that I can do it, but I didn't do venous intervention. So I'm qualified to do a little bit of that. Can we pick and choose? Can you train in all three and how does that work out? I'd be interested to hear from anybody who's on our panel here tonight. Yeah, Doug, I would say yes. The short answer is you are going to first and foremost be an interventional cardiologist who has to be completely facile with coronary interventions. You would be expected to have the cognitive knowledge base broadly for all cardiovascular interventions. And maybe the way I would frame this is there isn't this hard line between structural, peripheral, and coronary. And that's kind of what the document was built on. There are common building blocks of the profession. There are commonalities between different procedures where large-bore access is a good example that whether you do a high-risk PCI with hemodynamic support or you do a TAVR, that's probably where the highest risk and the most sometimes skill is required. And that's a common skill across both of those disciplines. So yes, the answer would be that if there are certain areas that you as an individual want to have a focus practice on, and it's also in the environment that you practice in. So if there's a need in a local community, we want to also make sure that the bar is not set so prohibitively high that we cannot offer appropriate therapy in all areas and all parts of our society. So we want to make sure patients are treated by highly competent individuals, but they also have widespread access. So yes, the answer is you can do all of those, but you would have to likely spend additional time and find the right environment to be able to get all of that training. Well, the Alucard description is very, well, very descriptive of what we're trying to get at is that we want people to train in the things that they plan on doing and that they stay within their competencies. So the label of a structural or a peripheral or exclusive coronary interventionalist, there's some blurring of those lines, and there's certainly blurring of competencies when people go in all these different directions. So we're not creating these artificial divides. An additional point, I think, to add, Doug, is that the competencies and the numbers are important. So for people to say, well, I did 50 peripheral interventions and 100 diagnostics, but not know when is the right time to refer a patient for common femoral endarterectomy versus doing it percutaneously means that they've not achieved the competencies necessary to practice peripheral intervention. And there are numerous examples for every procedure, be it coronary CTO or peripheral intervention or structural intervention in which managing the numbers in some places might be easier than actually the cognitive competencies. So it's important for the program directors and the fellows in training to recognize that they have to achieve all of the competencies in order to be really functionally well-trained. And while it's possible, I think Shami's point is well taken, that to be deep or broad depends on one's practice perspective, but you certainly need to make sure you have all those cognitive and clinical interventional skills. And this doesn't address the need for certification either. It's not enough to have just finished at the one time, but then to have continued the practice and expanded your toolkit as you go on in your profession. Yeah, I think that's a really important point. I mean, this is really a skill set for lifelong learning. You're not done. Like when you graduate, you don't just get the diploma and then that's that. I mean, I've been doing this for two decades and every single day that I go in, there's something else to learn. And to experience. And some of it is honestly, some of these competencies that are described, like a lot of stuff with venous intervention, although I trained in a lot of arterial intervention with a year of peripheral interventional training, we weren't doing venous interventions at a certain point. So I have a question for our panel. How does somebody who's a graduate, who's got their certificate, they're determined competent in a certain variety of some sub-discipline, whether it's peripheral, whether it's structural, how do they then go on and be deemed competent when they're fully-fledged independent practitioners? Can they go to a course? Does this document give us that sense? Should we have to do five venous interventions in any one area before we are independent to practice? And how does someone start that when they're actually in their own hospital and they might be the first to do it? I'll bite Doug. Just first, I want to point out that this is for initial training. The document, the scope of the document is for initial training. And I've heard Ted say it enough that I can hear it in my sleep. So I would say that, again, the scope of this document is for initial foundational training. And then I'll let Ted tell you what he thinks. Well, that is the scope of the document, that when they're done with their training, they know what they should be doing. They know the confines of what their practice should entail and they know what they shouldn't be doing. And learning after that, the truth is, it's a very hard thing to address. We tried that in 2013 when we did the competency for practitioners in terms of maintaining competency in procedural skills. And it gets very complicated and it has to do with their overall lifetime volumes and experience and how do we measure it. So we really kept this to a training document. That's helpful to know. I think it's important to cite those limitations or the sort of septation, if you will, almost, and how we can actually interpret this document and use it. Wayne or Fred, I'd love to hear your perspective from your own institutions about how you plan to use this with your fellows. At Mass General, it's very determined. Like there is a year of coronary interventional training. That's the ACGME accredited year. Does not start when you're a general cardiology fellow. It's separate. It's after you've graduated from an ACGME accredited cardiovascular disease fellowship. And then after that, you could decide if you want to do peripheral or if you want to do structural. Do you have more mixing and can people do it? And can they start before they've even graduated general cardiovascular disease fellowship at your programs? Well, so I can take that on. I think, you know, we're a much smaller institution, don't have the same sort of breadth of things that you probably offer at MGH. But we have a lot of our advanced fellows who actually do get involved in intervention, you know, before they actually, you know, are engaged in the actual training year. And some of that's by necessity because we don't have fellows that can cover every night, you know, in terms of an actual, you know, interventional fellow. And I've worked at other institutions where we have had no interventional fellows and I've done it with first year fellows. So, you know, it just depends on the institution you're at. And I think that speaks to, you know, the heterogeneity of training programs and the flexibility that this document sort of, you know, had to have. I think that one thing that we had to actually, for instance, a structural fellow for a few years and now we don't. And actually, I think the experience of our interventional fellows doing large bore access in many of our taverns has been hugely helpful for them. I think it's a great addition. Now, I don't think either of our fellows this year will likely go on to do taverns. I don't think they'll reach the 50 number, but it's been helpful for their practice. And I just wanted to follow up the one last thing because I was listening to all this conversation about lifelong learning. And I love the concept in this document about building blocks. Because, you know, if I look at my career, my practice today is completely different than when I was a fellow, right? We did no radial. I now do 90% radial. Structural intervention, you know, other than a little bit of mitral valvuloplasty was really nothing. And now I do structural interventions. And so, you know, over the course of 30 years, you're gonna evolve tremendously. The point is to have the structural, you know, that is the building blocks to be able to sort of adapt to these changes in practice. Yeah, this is Wade. I think Fred hit the nail on the head. This document, I think it's outstanding. It's a very, very difficult and a mammoth task to put this together. And I wanna just commend and congratulate the writing committee. There is no such thing as a perfect document, but I think as was stated, this provides a really nice framework on which fellows in training can build their skillsets. And at the end of the day, the most important stakeholder in all of this is actually the patient. And what I really like to hear, and what I've heard so far, is that this provides a framework by which individuals who get through these numbers and with on top of the basic skillsets that are required is gonna be safe to go out and practice. It doesn't mean that everyone's gonna have the same footing and the same degree of expertise, but this at least presents a very nice basic framework on which to build your skillsets. Lifelong learning is extremely important. I wanna echo that. And then the other thing is, documents have to change with the times. And what I really like about this document is there are some iterative changes relative to the past document. And it does make sense. To me, it has construct validity in terms of addressing imaging requirements, understanding that there's overlap in skillsets. The large-bore access thing is a huge deal. We've actually gone as far within our institution to create large-bore credentialing. So if you're a non-structural physician and you're an interventional cardiologist, if you wanna do cardiogenic shock call and implant Impella, not only do you have to be able to implant the Impella, but you actually have to have skillsets, basic training and foundational proof that you can actually safely get in and out of the basket of the tree with the large-bore access. So training changes, kind of like Fred, I started off with just the basic stuff and have layered on top of it. And I think that's an important message for fellows. Realize that this is not etched in stone. This will change over time. And so will your skillsets and your experiences. Last comment is when you're out in the real world and I think there was a question about how do I address on-the-job learning? I would say, go to your medical staff office first if you're gonna be doing something and you're gonna need some new credentialing. All hospitals are slightly different in terms of what their expectations are for added credentialing, especially if it's a new credential that maybe hasn't been already figured out. But just congratulations to the writing committee, an extremely difficult thing to do. I know it took two years and I know there was a lot of sweat equity in this, but I think it's an excellent document. These are great comments. Really terrific comments and really wonderful to help to put it in perspective. I see a number of questions from attendees that pertain to like, kind of how do I get a job? Like, how do I declare myself? How do I declare that I have the competency to do what I wanna do? What's the market like afterward? And so I just wanna ask again of program directors, like at your institution, Dr. Pham's got a remarkable institution where she's able to train and in six months have tremendous volume. There are others where maybe because of volume of fellows or numbers of procedures that are done may be hard during their one accredited ACGME year to get something other than coronary interventional experience. What do you recommend? I know it's beyond the scope of the document, but this is what people are here to hear about. How do I get my job? How do I learn how to do what I wanna do? Do people have to spend another year? Do people like, how do you get just like those two extra months to get that volume? Like, where do you do that? How do you do that? And I just wonder what your practical advice is. I know it's beyond the extent of what we're describing here in the document though. I would say this is a really tricky issue that we deal with a lot. And one of the reasons that we don't have a structural fellowship right now is because of the job situation. And we probably need to do some more work as a society and as a profession of really understanding what the needs are of the population. And I don't know that we really have done a good job at sort of planning our workforce. But I think the simplest thing is for people to sort of follow what their passions are. So, we've had people who just love structural, go do it. And I think most of our fellows who have had that passion gone have been able to find jobs but I do sympathize. I know that it's tough and it may not work out completely but I think the only thing you can advise is to follow your passion. There's a distinction between training and your education and the needs and the requirements of a workplace. And as a trainee, you should have as big and broad an education and as deep an education as you'd like. And in your workplace, you may have different requirements of what's needed for you or needed by the hospital or by your group. And so you should think about these two things a little bit differently. No one can take your education away from you. No one should limit your education except for you and your decision about what depth of training you wanna go to and how long you wanna spend on it. But that may be different than what your workplace requires. So try to keep this perspective that workplace is different from training but education is very valuable. You'll never lose what you learn. That's only going to help you down the line. So even if you don't practice a single procedure related to something esoteric that you learned, you will have learned that skill and you never know where that's going to pop up in your practice or when you're gonna be called on to perform that duty. So just be mindful of education and training versus workplace issues. Yeah, I would add only, Doug, that the vascular field is persistently hot, and atherosclerosis is what we take care of throughout the circulation. And so I do think that workforce needs are a market force, and certainly I think that vascular training is compulsory, especially when you're called to bail out your structural colleagues from a vascular complication. So I think that those skill sets are evergreen, just as Anna said, everything you learn in training will be applicable, probably sometime in the future, and to get broad based training is critically important. But if one is focusing in a certain area I think that those training and vascular have numerous opportunities in the in the current environment. And so it's, it's my sort of tongue in cheek encouragement to those out there to seek additional training in vascular. I agree with that. And if you look at the distribution of of interventional health care. If you look at the number of interventionals we have and we've done this through society years ago we were looking at this. And it's not that there are too few it's just most often it's just the distribution so inequitable, and so there are places where there are these gluts and you look at the average caseload for interventional cardiologists and it's extremely low. And by having these other procedures, such as the vascular procedures that CEO was talking about, it's a way to keep your skills up and current, at least from a procedural standpoint. Yeah, I just have three comments. First, I completely agree with Fred we need, we've never done a deep dive into the workforce requirements we have done some as Ted pointed out and we certainly haven't addressed, based on the population distribution. So that's something maybe the Society of the college could entertain. The second is I really like Anna's comment it's crucial for everybody to know when you're training or getting an education, this is a luxury you learn you for something that makes you a better physician better interventionalist, and you then will have a better cognitive knowledge base as well as understanding what the technical know how is so everybody doesn't need to necessarily be an expert in every aspect of cardiovascular interventions, but to get exposure during training is something that you should because it will help you throughout your career. And then the third part is something that this is the training that question you asked at UC San Diego. I've had a two year interventional training program for 20 years. So, even though I felt very strongly that we cannot mandate that second year, and our second year is pretty broad. So, we are trained in peripheral structural. If somebody wants to be more research oriented they spend some time there. So the thing I always advise trainees is get the broad knowledge, but then try and be vertically, an expert in an area and that area doesn't have to be as strict as structural coronary or peripheral, but pick an area that is your area of expertise, and then hopefully that will translate into wherever you end up working gives you that extra edge for a job. Yeah, really really well put that appreciate that. I have one particular question here for those of you who are so directly involved in the writing of the document. I know I've been on a guideline writing committee, especially when you involve multiple different societies. It involves a lot of compromise, you might come to the table with certain ideas and things that you want to navigate or negotiate for. And sometimes it has to change because you're trying to find consensus and build consensus among people. Was there anything as you came to the table to write this document that you felt you had to give up. Was there some sort of compromise or was it just all, you know, apple pie and mom and everything was agreeable, and it just was perfectly smooth to write this and you came up with something that all agreed upon. I think Ted is the right person to answer this question because he guided us through this superbly. Well, the dictum was if we're all a little bit unhappy. We probably did a pretty good job. And I've been through this once before. And it dramatically changed how I approach I approach personally I approach this, this episode of writing about competency. So, you stay open to ideas and look the original numbers. The original numbers were the story I got from two of my mentors when was Spencer King and Tom Ryan, when he was my chief in Boston, or that they were out on a golf course and they were thinking it was about the time that they were beginning to think that interventional cardiology should probably be a subspecialty board certification process how many numbers. How many do you need. Now Tom never did one in his life and Spencer did quite a bit quite a few but it was less a practitioner at that time. than a researcher a speaker and a thought leader, and, and they said well maybe we for one year you do one a day and they're 50 weeks in a year and you have two weeks off and we came with a number 250. And that was that was the science behind that actually pretty good number. I thought the number when I first started should be much higher. I was younger, and the world was more black and white. Then I had some growth in terms of health care and equities and distribution of health care resources and figured that it's it's as important to have people have access to health care, especially the health care that we give. And it's, you know, this is what it is it's a consensus statement it's drawn by the experience even the expertise of these 40 people and all the people that helped us from the various societies and the reviewers and, and the commentary, the comments and we tried to incorporate those and find a middle ground. So yes, it was painful. Yeah, I would just like to add that, you know, as a, as a data driven person, you know, looking for that data as Ted was saying, it really doesn't exist but what is really reassuring is that when you do research on procedural volume within our specialty we find that there's very little, if no correlation between the operators experience by number of procedures or years in practice, and their outcomes, and I think that's because people are practicing within the scope of their experience and taking on more complex and high risk cases. As you know their career matures. And there are of course the highest risk cases which fellows have to deal with day one, which is they're on call and there's a PCI with cardiogenic shock. And I feel like if we try in any way to limit the types of procedures or credentialing that individuals can have that that's highly detrimental because you never know what you're going to face when you're on call and you need to have all those skills. So that always comes to mind. And, and I do think a lot of outcomes have more to do with the institutional and overall institution volume experience than it does with the operator experience. So understanding the environment in which you practice is highly important. What the skills are of the people around you and the consultants and the specialty expertise is really important and and that's really pertinent to trainees. I've been a program director for 12 years just trying to advise people on what is the setting they're going to practice in. And, you know, if you're coming out of practice going to into an institution where there's, you know, no surgery on site or if later in your career you want to practice in an OBL or ACS. These are, you know, considerations in mind, but, you know, well beyond this document. And, you know, lastly with the two year thing. Interventional is one of the longest training pathways of any specialty. We could all be vascular surgeons or mostly neurosurgeons or, you know, I did nine years of training a lot of people in this panel did quite a few. And, you know, maybe in the future we could look at consolidating some other aspects of training to allow a greater depth of interventional training but at this stage it wasn't on the docket for this document. And I think all of us felt it was really unnecessary and would be highly detrimental to the diversity in our field to really prolong this any more than it already is. Talking about in a minimum being a PGY seven when you enter interventional cardiology. So those are just the points I wanted to say. I think these are incredibly practical points I mean because at the end of the day, it's how long can people dedicate to achieving these skills. How much do we have to be dogmatic about a so called dwell time, as opposed to the establishment of competencies or the achievement of milestones and I think you've done a really beautiful job articulating that both as you're speaking now but also in the document itself to consider the evaluation of competencies as they're achieved, and not just dwelling on the idea of numbers. I think personally, you know doing one PCI nowadays compared with the way it was 20 years ago is like doing four of the type A lesions maybe that we once had done. It's few and far between right now. So, anytime you do one case and you make it through it when it's as complex as they are, it feels like you have enough experience of multiple. So it's curious to me to see that numbers, you know, are are still featured in the document like this because some of it is just how much have you actually done, what can you do, what have you learned what do you know how to do. And I think that that's always been a real focus or attention I will say in the co cats documents of being focused on the achievement of milestones, as opposed to either numerical months of experience for general cardiology fellow or number of studies read or And so I'm just curious, maybe in the final moments that we have to hear from program directors about how do you map this out, how do you actually use this. Are you planning to get down with a slide rule and or a piece of chalk on a chalkboard and mark this, or is there interpretation of this because so many of the questions that were asked were like hey if I do an intravascular imaging study plus a piece yet as it counts more than one if we're doing to lesions. There's gonna be a lot of questions about all this so can I can I interject something for a quick second here. So, you bring up a great point, and that is I think the document puts a lot of pressure on program directives. That's always been there, but it really focuses that the in procedural or surgical competencies the people who are working with you know whether or not you're competent. I mean, there are numbers and experience and all the volumes are are all there but they know that. And the program directors now I for six years I was chairing the board writing committee. And one of the things that program directors have to do is certify whether or not the applicant for board certification in interventional cardiology is competent to take to stand to sit and take the boards. And if they're not they should be disqualified. And those letters are those those comments would go to the person who was in my position. So in six years I received no letters. None. It was a rubber stamp. And I think that has things have to change that the people who are the outliers, and they either have to be intervened on in a positive way maybe redirected, maybe to a career that will make them more satisfied and happier and better serve their patients, or they have to be accurately. Ted. So they just don't go along this ascent into a position where they may be, you know, not the best practitioners, or develop competency over time, you know, with appropriate supervision mentorship direction. What's what's what's those kind of programs are organized. Yeah, absolutely. So Wayne bachelor I know you had a comment that you wanted to make that that was really astute and maybe some final point here for us before we conclude so I'd love to hear from you. Yeah, I think a part of learning that is so important for us to recognize this understanding how to know your limits and understanding how to how you can learn from others. Part of that is the understanding the role of the multidisciplinary heart team, you know, to be a good interventionist nowadays, you are, you absolutely have to understand how to work within teams, their system based approaches to things like structural heart disease incorporates multidisciplinary heart team, high risk PCI etc so you know reading between the lines I think this is inherently obvious and the training competency document but I just want to emphasize for fellows coming out. Part of your responsibility is to understand when to call for help, and also how you fit in to the multidisciplinary care of the complex patients you're going to serve so just a little plug for the multidisciplinary heart team in this. I think that's a really incredibly important point to make. And I think that while we spend so much time and effort, talking about medical knowledge and clinical skills, other competencies, such as systems based practice knowing how to navigate and work within a system collaborating with others, you know, Don as you were saying maybe you're working in outpatient based lab or other different type of facility but knowing how to learn that skill is a whole nother round of competencies that are the non clinical competencies that really helped to kind of buoy us and improve our care as we continue to mature and develop in the field. So, I think we're at time right now so I'll take the the moderators prerogative. I'd like first and foremost to thank and congratulate all of the authors framers of this important document to particularly thank those of you who have been able to spend the evening with us here and share your perspective, the presenters, the panelists, and as attendees for all of your thought provoking questions. Once again, I just want to say thank you on behalf of sky on behalf of ACC on behalf of the American Heart Association, all of the various societies who have participated in this. Thank you so much for all of your engagement and congratulations and I hope you all have a very good evening. Thanks for joining us.

interventional cardiology training

competency

transition

implementation

fellowship programs

specialization

knowledge base