Subspecialty Training in Preventive Cardiology: The Current Status and Discoverable Fellowship Programs

Abstract

Background:

Preventive cardiology is currently not an American Board of Medical Specialties‐recognized subspecialty. However, several programs offer nonaccredited fellowships throughout the country. No source currently exists listing all available programs, and finding programs requires time‐intensive search strategies. Our aim was to find all current preventive cardiology fellowships in the United States and describe their basic structure, duties, and faculty.

Methods:

We searched the Internet, contacted national organizations, and networked through any institution thought likely to have a fellowship.

Results:

We found 15 programs currently offering subspecialty training in preventive cardiology but with considerably different styles, structures, duties, clinical time, lengths, and hosting departments.

Conclusions:

We provided a list of these programs and discussed the implications for the future of formal subspecialty preventive cardiology education. © 2012 Wiley Periodicals, Inc.

Dr. McBride is codirector of one of the fellowship programs listed, but otherwise has no relevant disclosures. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Introduction

Nearly 10 years ago, the American College of Cardiology (ACC) stated, “The need for a preventive academically oriented cardiovascular specialist has never been greater.”1 They concluded that there was a significant shortage of academic preventive cardiovascular specialists primarily because of the “relatively small number of training programs available to cardiology fellows with specific preventive subspecialty training.” As cardiovascular disease (CVD) remains the leading cause of death in the United States,2 the continued need for advanced subspecialty training in and focus on preventive cardiology remains high.

To help close this gap between training needs and availability, the Core Cardiovascular Training Symposium III Task Force 10–Training in Preventive Cardiovascular Medicine (COCATS)3 outlined requirements for advanced training by designating competencies for level II and level III training (6 months and 12 months specialized training minimum, respectively). However, many institutions do not have prevention‐oriented role models capable of providing in‐depth subspecialty training. Consequently, an interested cardiology fellow may need to look outside his or her fellowship for advanced subspecialty training opportunities. Potentially, this “may require additional formal education beyond a basic 3‐year [cardiovascular fellowship] program.”3

Because preventive cardiology is neither an Accreditation Council of Graduate Medical Education (ACGME)‐ nor an American Board of Medical Specialties (ABMS)‐recognized subspecialty,4, 5 there is no clear organization charged with keeping a current list of fellowships offering extended training in preventive cardiology. Furthermore, there is no standard curriculum, no governing board, and no certifying body. Although the American College of Cardiology Foundation specified several methods to achieve formal training,6 a formal preventive cardiology fellowship is not listed as an option, and there is no list of current fellowships provided or referenced. Consequently, a prospective trainee interested in completing a preventive cardiology fellowship is left to his or her own devices to discover, evaluate, and compare any fellowships found.

The aim of this article was to catalog and describe all current subspecialty preventive cardiology fellowships including their basic content, structure, and faculty. We did this as a means to assist others interested in subspecialty preventive cardiology training and to establish the status and format of current opportunities in the United States.

Definition

For the purposes of this article, a preventive cardiology fellowship is defined as an established funded program that offers postgraduate training in preventive cardiology to MDs, DOs, or PhDs, and can offer a cardiology fellow certification at COCATS level III in preparation for becoming a director of a clinical service, research program, or both.3 These programs offer clinical and/or research experience in at least 1 aspect of CVD prevention and have a specific focus in cardiovascular prevention.

We excluded the following program types: preventive medicine residency, as well as general cardiology, nephrology, endocrinology, or vascular medicine fellowships. An up‐to‐date list of the first 4 training programs is carefully kept by the ACGME, which certifies and monitors each of these fellowships.4 The vascular medicine fellowship is not yet ABMS/ACGME recognized, but the National Heart Lung and Blood Institute (NHLBI) keeps a list of its sponsored institutions7 among several other non‐NHLBI programs across the country. Each of the above 5 training programs usually offers the chance to gain some expertise in prevention and should be considered as a potential route to expertise, but will not be discussed in this article. Last, we excluded fellowships exclusively intended for postdoctoral PhD candidates.

Methods

The Internet was searched using terms such as “preventive/preventative cardiology fellowship,” “lipid fellowship,” “hypertension fellowship,” and “atherosclerosis fellowship.” The Society of Preventive Cardiology, National Lipid Association, and the program directors list for the American College of Cardiology were each emailed asking for potential programs, but none of these groups responded. Academic centers that we felt were likely to have a prevention fellowship were contacted individually. In addition, when programs were discovered, further networking was done to find other fellowships.

Information about each identified program was then obtained from pamphlets, flyers, Web sites, or through personal contact with program directors and support staff. Program directors' names were requested and programs categorized. We considered a program to be clinically oriented when clinical duties occupied ≥70% of the time and research oriented when research occupied ≥70% of the time. A designation of mixed means that a program has neither clinical nor research component ≥70% of the time. A dedicated Web site means the Web site is clearly labeled and discoverable through an Internet search as a fellowship opportunity in preventive cardiology.

Results

We identified 15 fellowship programs that offered funded postgraduate training in preventive cardiology (Table 1). There were 23 positions available per year, and 10 fellowships (66%) are 1 year in duration. Fellowship length varies between 1 and 3 years. Fellowship structure generally falls into 2 broad categories: research focused, lasting 2 to 3 years with incorporated additional degree, or mixed clinical/research focused, lasting 1 year in length with 50% clinical and 50% research. By our definition, 1 program (7%) was clinical, 8 (53%) were mixed clinical/research, and 6 (40%) were research. Ten (66%) fellowships are hosted by cardiology departments, whereas others are hosted in internal medicine, preventive medicine, community medicine, and aging. Five (33%) of the programs also accept PhDs for training. Seven programs (47%) offer master's degrees. Nine (60%) programs maintain a dedicated Web site.

Table 1.

Preventive Cardiology Fellowship Programs in the United States

Name and Location	Program Director(s) and/or Contributing Faculty Member	Host Department	Length, y	No. of Positions	Prerequisite	Duties	Degrees Offered	Application Deadline	Dedicated Website	Most Representative Web Site
Baylor College of Medicine,13 Houston, TX	Vijay Nambi, Christie Ballantyne	Cardiology	1	1	MD	Mixed	—	September 30th	Yes	http://www.bcm.edu/medicine/athero/index.cfm?PMID=6441#Dir
Brown University,14 Providence, RI	Gideon Koren, Charles Eaton	Cardiology and Pulmonary	2–3	2	MD or PhD	Research	MPH, MS	Rolling	No	http://www.brownmedicine.org/cardiopulmonary/index.html
Cedars Sinai,15 Los Angeles, CA	Noel Bairey‐Mertz, Predeman K. Shah	Cardiology	1	1	MD	Mixed	MPH	December 1st	Yes	http://www.cedars‐sinai.edu/Medical‐Professionals/Graduate‐Medical‐Education/Fellowship‐Programs/Womens‐Health.aspx
Columbia University,16 New York, NY	Lori Mosca, Henry Ginsburg	Internal Medicine	1–2	1	MD or PhD	Research	—	March 31st	Yes	http://www.hearthealthtimes.com/professionals/training.html
Emory,17 Atlanta, GA	Laurence Sperling, Terry Jacobsen	Cardiology	1	1	MD	Mixed	—	Rolling	No	http://www.emoryhealthcare.org/cardiac‐rehabilitation/index.html
Hartford Hospital,18 Hartford, CT	Paul Thompson, Gary Heller	Cardiology	1	2	MD	Clinical/Nucleara	—	December 31st	No	http://www.harthosp.org/heart/PreventiveCardiology/default.aspx
Harvard VA,19 Cambridge MA	Michael Gaziano, Luc Djousse	Division of Ageing	2	2	MD	Mixed	MPH	Fall Season	No	http://www.brighamandwomens.org/Departments_and_Services/medicine/services/divisionofaging/OurResearch.aspx
Mayo Clinic,20 Rochester, MN	Francisco Lopez‐Jimenez, Randall Thomas	Cardiology	1	1	MD	Mixed	MS‐CI	August 31st	Yes	http://www.mayo.edu/msgme/cardiopreventive‐rch.html
New York University,21 New York, NY	Joseph Ravenell, James Underburg	Cardiology	1	1	MD	Mixed	—	November 1st	Yes	http://medicine.med.nyu.edu/cardiology/education/fellowship‐introduction/advanced‐training‐programs/preventive‐cardiology‐fellowship
Northwestern University,22 Chicago, IL	Martha Daviglus, Donald Lloyd‐Jones	Preventive Medicine	2–3	1	MD or PhD	Research	MPH, MS‐CI	January 31st	Yes	http://www.preventivemedicine.northwestern.edu/Divisions/cardiovascularepidemiology/index.htm
Providence VA,23 Providence, RI	Wen‐Chih “Hank” Wu, Gaurav Choudhary	Cardiology	1	2	MD	Mixed	—	Fall season	No	http://biomed.brown.edu/facultydirectory/profile.php?id=10391#
St Luke's Mid America Heart Institute,24 Kansas City, KS	James O'Keefe, John Spertus	Cardiology	1	1	MD	Mixed	—	July 31st	Yes	https://www.saintlukeshealthsystem.org/medical‐allied‐health‐education/cardiovascular‐education/preventive‐cardiology‐program
Stanford Hospital,25 Palo Alto, CA	Christopher Gardner, Thomas Robinson	Prevention Research	2	2	MD or PhD	Research	MPH, MS‐Epi	December 1st	Yes	http://prevention.stanford.edu/education/fellowship/
University of Rochester,26 Rochester, NY	Thomas Pearson, Susan Fisher	Community and Preventive Medicine	2	3	MD or PhD	Research	MPH, MS‐CI	Rolling	Yes	https://www.urmc.rochester.edu/cpm/educational‐programs/postdoctoral‐programs/preventive‐cardiology.cfm
University of Wisconsin,27 Madison, WI	James Stein, Patrick McBride	Cardiology	1	1	MD	Research	—	Rolling	No	http://www.cvrc.wisc.edu/airp/

Abbreviations: Mixed, mixed clinical and research duties; MPH, Master's of Public Health; MS, Master's in Science; MS‐CI, Master's of Clinical Investigation; MS‐Epi, Master's in Epidemiology; VA, Veterans Administration.

^aSix months is clinical preventive cardiology, and 6 months is nuclear cardiology.

The MD prerequisite for training was having completed a residency in internal medicine or less frequently in family medicine. Although not specifically excluded, we found that nephrology, endocrinology, or vascular medicine fellows were not the anticipated applicants for these fellowships. Having completed a cardiology fellowship is usually a desired experience, but is often not required. Discussions with program directors indicated that most MD applicants are internal medicine residents who eventually plan to complete a cardiology fellowship, or less frequently, cardiology fellows interested in a career in preventive cardiology.

At each institution we found broad expertise in most areas of preventive cardiology among the various faculty members. However, we also found significant variability in the prevention philosophy, clinical focus, clinical populations, faculty research expertise, and ongoing research activities. Due to the substantial diversity among programs, as well as their variety and breadth, we did not categorize fellowships by specific prevention topic expertise.

Discussion

Our search for preventive cardiology fellowship programs yielded 15 training programs. We acknowledge that despite considerable effort, this list may be incomplete. However, extensive searching identified only the programs listed, and only 60% maintain clearly discoverable Web sites. We identified several academic centers interested in creating a fellowship in the future, but excluded them due to a lack of a defined timetable or funding.

We found wide diversity among programs, each with key features, faculty, research projects, and clinical work that made each a unique opportunity. As there are no specific guidelines regarding subspecialty training in preventive cardiology, this variety and diversity should be expected. Given the variety of programs, we strongly encourage prospective applicants to visit Web sites, talk with program directors, perform literature searches on the relevant faculty, and individually explore each fellowship‐training opportunity. As the last step, an onsite interview will help to fully match the best applicant to the appropriate fellowship.

Only one program was clinically oriented by our definition. This suggests that for most preventive cardiology fellowships, there is a significant emphasis on research. The large numbers of programs offering additional degrees corroborates the importance of research within preventive cardiology training programs.

We emphasize that training through one of these preventive cardiology fellowships is not the only way to attain expertise in preventive cardiology. For example, several academic cardiology fellowships offer 4 years of training, with up to 2 years of research and elective time (personal communication with Dr. William Kraus, Duke University; Dr. Roger Blumenthal, Johns Hopkins). In such programs, expertise can be obtained during cardiology fellowships, with competency established in 6‐ to 12‐months training time following COCATS guidelines.3 Other opportunities for developing expertise are through individual certifications such as becoming a clinical hypertension specialist,8 a clinical lipid specialist,9 or a certified obesity medical physician (a newly created certification expected in the fall of 2011).10

Given the magnitude of the burden of CVD in the United States, and the growing recognition of special expertise in preventive cardiology, we believe there remains an unmet need for training the future generation of academic‐minded preventive cardiologists. A recent survey11 demonstrated that 30% of institutions do not have a prevention expert in their cardiovascular faculty. Furthermore, only 30% of US cardiology programs provide their general fellows with the COCATS‐recommended 1 month of preventive cardiology training. These are similar data when compared to studies from 10 years ago,1, 12 suggesting that the training gap among general cardiology fellows previously identified in preventive cardiology training persists today, at least partially due to the lack of specially trained CVD prevention experts.

If we are to close this education gap, several things should be done: increase the number of fellowships, standardize the fellowship experience, and work toward ABMS recognition. This trio would (1) increase the supply of academically minded preventive cardiologists, (2) clarify the training pathways and needed expertise, and (3) increase the national recognition of the specialty. If successful, such an effort would likely have a significant impact on reducing CVD in the future.

Conclusion

The goal of this project was to identify training programs for individuals interested in obtaining subspecialty knowledge and skills in the field of preventive cardiology, as well as to establish the current status for advanced training opportunities in preventive cardiology. Potential applicants will now have access to a defined list of 15 current preventive cardiology training opportunities. Each prospective preventive cardiology fellow will need to assess his or her individual interests and goals for the future, including interest in clinical exposure; research training; or specialized knowledge, skills, and procedures. Interests in epidemiology, population health, and clinical opportunities should all be considered prior to choosing a program. In the future, national professional organizations may wish to consider specific fellowship standards and certification.