Interest in Advanced Heart Failure and Transplant Cardiology Fellowship

Despite increasing heart failure (HF) prevalence and expanding therapies, National Residence Match Program data demonstrate vacancy rates of 38% for advanced heart failure/transplant cardiology (AHFTC) for the past 4 years. AHFTC physicians have been surveyed, but actionable perspectives from trainees are missing.^1,2 Thus, we surveyed general cardiology and non-AHFTC subspecialty fellows to explore factors that influence subspecialty choice to study the hypothesis that differences exist between those interested/committed to an AHFTC career (AHFTC respondents) vs those interested/committed to a non-AHFTC career (non-AHFTC respondents).

A 44-item survey was developed using published reports and expert opinion.¹ The survey was distributed anonymously through the Research Electronic Data Capture from January 27, 2023, to March 9, 2023, to cardiology trainees via the American College of Cardiology (ACC) Fellows In Training (FIT) listserv with follow-up encouragement through social media. Potential participants were incentivized with 5 $50 gift cards in a lottery. Standard descriptive statistics such as Fisher exact test and Student’s t-test using R (version 4.02, R Foundation) were used to determine demographic differences between the 2 groups as ordinal, discrete data due to a non-normal distribution as determined by a Shapiro-Wilk test of normality. The study was approved by the Atrium Health Wake Forest Baptist Institutional Review Board.

Of the 5,079 participants in the ACC FIT listerv, there were 419 eligible survey respondents, giving a response rate 8%.³ A dual-method analysis for nonresponse bias was performed and found no significant nonresponse bias.³ Of the 419 included respondents, 78 were AHFTC respondents (18.6%), and 341 were non-AHFTC respondents (81.4%). The average age of participants was 32.8 ± 3.1 years; 64.4% were men; 45.6% were White; and 83.8% had an allopathic medical degree. Most respondents were in general cardiology training (89%). The proportion of those interested in AHFTC was larger in the current study when compared to 2023 National Residence Match Program match data (71 matched positions in AHFTC, 1,152 for general cardiology, 129 for electro-physiology). There was a greater proportion of women among the AHFTC vs non-AHFTC respondents (45.5% vs 32.1%; n = 0.037).

Comparison of the groups’ interests/incentives are represented in Figure 1. Clinically, both groups expressed strong interest (defined by rating ≥4) in cardiac critical care and cardiogenic shock, but there was greater interest among AHFTC respondents (P ≤ 0.001 for both). For desired patient interactions, patient acuity/complexity was the highest incentive in both groups, but AHFTC respondents were more likely than the non-AHFTC respondents to rate this strongly (P = 0.001). More AHFTC than non-AHFTC respondents rated longitudinal relationships with patients (P = 0.003) or multidisciplinary approach (P = 0.009) to be important (rating ≥4).

FIGURE 1.

Respective Interests/Incentives in Order of Descending Interest by AHFTC Respondents

Horizontal bar graphs represent the percentage of respondents in the 2 categories of advanced heart failure/transplant cardiology (AHFTC) respondents vs non-AHFTC respondents for (A) heart failure (HF) clinical topics, (B) the nature of patient interactions, and (C) career characteristics. *MCS to include temporary mechanical circulatory support; ^‡Device-based technologies to include Barostim (CVRx Inc) and cardiac contractility modulation as examples. HFpEF = heart failure with preserved ejection fraction; LVAD = left ventricular assist device; MCS = mechanical circulatory support; QI = quality improvement.

Among career characteristics, positive role models were the highest rated incentives in both groups (87.2% of AHFTC vs 83.9% of non-AHFTC respondents with rating ≥4). Research (P = 0.012) and administrative opportunities (P = 0.012) were more frequently strong (rating ≥4) interests among the AHFTC vs non-AHFTC respondents. Fewer AHFTC vs non-AHFTC respondents rated the following factors to be an important (≥4) incentive: work schedule (P = 0.023); compensation (P = 0.014); and geographic flexibility (P = 0.006).

These results offer actionable data points for opportunities to potentially increase interest in AHFTC training. Clinically, the robust interest in cardiogenic shock and cardiac critical care among AHFTC and non-AHFTC respondents suggests a potential gateway for interest in AHFTC training. With a recent study demonstrating superior outcomes in AHFTC-led critical care units,⁴ more standardized involvement of AHFTC cardiologists in this space would have the potential to engage learners who might otherwise be swayed to other subspecialties and could additionally expand practice opportunities in cardiogenic shock beyond the walls of transplant centers.

As non-AHFTC respondents were more likely to be incentivized by a cluster of lifestyle considerations, including 1) geographic flexibility; 2) compensation; and 3) work schedule, addressing work-life balance in the field of AHFTC may improve interest. Despite longitudinal profitability for institutions with advanced HF therapies, a 2021 MedAxiom survey reported that HF cardiologists had a lower median compensation than cardiology peers, even after considering work-relative value unit adjustments for greater patient complexity. Compensation models likely need to be updated. Normalizing careers outside of traditional transplant centers would also increase geographic freedom after matriculation from AHFTC training. Further investigation of real-world HF practitioners may also address perceptions vs reality of HF career opportunities. Lastly, it is important for regional and national leaders to embrace academic mentorship, behavioral integrity, and empathy for trainees.

This is the first large survey of cardiology trainees to determine perceptions and motivations surrounding AHFTC training. As with most surveys, the response rate was low at 8%. However, our formal nonresponse bias analyses were reassuring.³ Survey responses were not limited to 1 response, so multiple responses could have been submitted by a single subject to increase chance for incentive through the ACC FIT listserv or through the follow-up social media links, which may have additionally lowered the actual response rate.

In summary, this survey of cardiology fellows identified significant differences in factors influencing subspecialty selection between AHFTC respondents and non-AHFTC respondents that could inform efforts to revitalize interest in AHFTC training.