Chapters Transcript Video Starting a Cardiology Fellowship: the Good, the Bad, and the Rewarding Dr Sneha Vakamudi describes the strategy and leadership roles needed when structuring a cardiology fellowship program. Thank you guys so much for having me. Like I said, it's a pleasure to be here, especially with so many familiar faces. Um, I'm gonna talk to you guys about the challenges, opportunities, and strategic considerations of starting a fellowship, and I've heard it's good timing because I've heard you've got some new fellows joining in July. Um, like Div said, I am the current program director at the University of Texas Del Med School. It is, uh, the cardiology fellowship is in partnership with a private practice, Ascension Texas Cardiology that I'm a part of, um. So here is our agenda for an hour we're gonna go over the big question of of why start a fellowship at all. Um, I'll talk a little bit about some of the ACGME requirements and infrastructure that I think are important to have a successful program. Um, we'll spend some time talking about sustainability and long term planning. The commitments you need to have a successful fellowship. Um, we'll talk about designing a curriculum, and I'm gonna end with a decision roadmap, which is essentially a set of checklists that you can use not only in planning and building the fellowship, but within that first year of launch, which is a really important time. So the big question of why should we start a fellowship. So this is a strategic and resource-based decision that really requires alignment of institutional goals and faculty readiness. Because there are a lot of rewarding reasons to start a fellowship. Um, fellowships enhance the academic reputation of program. It also attracts strong trainees and faculty. Within our own program we've been able to recruit from some of the top academic centers for cardiology across the country, and one of the major reasons people are excited to join our group is because of the fellowship and not only just because we have a training program, but I think people are actually excited about starting a new training program that they can kind of mold and craft. In addition to having um. Fellowship help with recruitment of faculty, uh, having recruitment of fellows increases your visibility to internal medicine departments across the country, um, which increases chances for collaboration on clinical research and educational initiatives. We have fellows that come from some really great places within Texas like UT Southwestern, but we also recruit from all across the country, including places like the University of Michigan, Ohio State, and WashU. Having a fellowship can help expand your research productivity. Within our group we we were already a really big clinical trial center. We have about 55 to 60 active clinical trials going on at the same time, but adding the fellows has allowed our faculty to increase the breadth of their scholarly activity. We now write book chapters. We participate in educational articles through the ACC. Um, I have a bioengineering project that kind of got brought up through the fellowship that is a cross collaboration with the undergraduate biomedical engineering department. And having that institutional back and forth when you, when you share fellows, when you have faculty, um, work on projects with other places has actually allowed some of our faculty to uh get onto guideline statement articles. And then finally, having a fellowship can play some important roles of addressing workforce needs and also driving program growth and quality. Um, you can have fellows that you can recruit into some really hard to fill spots like advanced heart failure and structural imaging. So this is a picture of us doing a tier case in the cath lab. Um, in the front is one of our 3rd year fellows, Lux Trevetti. Lux is a great fellow who came to us, um, from UT Southwestern, and he had an interest in advanced imaging, and he also wanted to stay in the Austin area after fellowship because he grew up there. Um, at the same time, we had two major needs. We had a satellite hospital that really needed someone to champion echo and other imaging qualities such as CT, and they needed an echo lab director. And then we have a growing structural program, so I needed someone to kind of back me up on structural imaging and had adequate skills to do so. And so we were actually able to crack. His training over 3 years to fulfill those two roles. He's happy because he has a good job with people he knows in the roles that he wants to do, and then we're happy because we didn't have to recruit externally. I have someone who I know has great skills, and I already know I'm going to be excited to work with him. And so it's kind of really a win-win situation. And then fellows, I really think also help improve the standardization of care. You will never check yourself more carefully in patient care than when you're working with a fellow. And then also when you have things like regular case conferences and case reviews, um, discussion of patient care really helps bring up standardization and can highlight strengths and weakness of a program, and, and you can really work together to improve best practices across the system. But starting a fellowship is not without its own challenges. Um, institutions really need to spend some time thinking about how they're going to protect faculty time, um, make sure that there's adequate administrative support, and really make a long-term commitment for a program that you hope to have not only for a year or two, but ideally the life of an institution. Um, we are an RVU based model. Uh, places with RVU-based models really need careful consideration of how you will financially or administratively support the time that faculty take to teach fellows. Fellows, especially in the first few years of your program, will not make you faster or more efficient. Um, but there, there are wonderful things that come along with it. So as a group, you just kind of have to think about how you're going to support that time. This chart to the, um, the right is actually pulled from the ACGME cardiovascular, uh, fellowship guideline. Um, let me see if my, I can get a pointer here. So. You can see that the amount of minimum required FTE that a program gets is based on their complement of fellows. So we have 3 fellows a year, so a total complement of 9. So the minimum allotted FTE for APDs and core faculty is only 0.2, which is 0.2 spread across all those people. When you add in a program director, it goes up to 0.58. If you have one program director and a handful of faculty, that might be plenty if you have 3 or 4 faculty. We have a group of 40. A 0.2 FTE spread across 40 people just doesn't go very far, um, and it can be insufficient. In addition, having inadequately trained staff or insufficient case volumes can launch a program prematurely and really create a bad experience for everyone and, and have a negative experience and faculty will disengage really quickly and institutions really don't have often recourse for that. Um, institutions often underestimate the large administrative and GME workload that goes along with having a fellowship. Uh, as a, as a physician, I really viewed fellowship from my past lines as a trainee and didn't really understand until I got into the program director role, all the work that goes along in the background to do things like offboard, graduate, or even interview a fellow. Um, and money is always an issue. Having fellows, I, I make an analogy, it's a little bit like having kids. I love my kids, they're the best part of my life, but they're expensive. Um, and especially in those first few years, um, making sure you have sufficient funds or resources as an institution for the fellowship is important. Um, external sources of funding, I think, are really important. It's something I'm happy to talk about a little bit more later during discussion. Uh, to help make sure that your trainees have sufficient resources, even in spite of changes in fellowship costs or hospital budgets. So our program runs a fellowship endowment, uh, that's invested to make sure that no matter. No matter what happens with budget cuts or, you know, other GME programs expanding and GME reallocating funds that that our fellows have sufficient resources to do things like travel to meetings, pay for new workspaces, um, or, or anything else that might come up. So next we'll go to requirements and infrastructure. So program leadership is a core part of having a training program. Strong leadership can really create and define the identity of a program. As a PD, my fellows know that I'm gonna hold them to really high standards, but, but as a converse, I'm very accountable for things I do, and they know they can always reach out. To me if they have a problem. In addition to the program director, APDs are important and can really elevate the academic mission and play a complementary role to strengthen the PD. I have 3 wonderful APDs who you see on the right hand side. Chris is my interview champion. Chris is the one who herds all the faculty and gets them ready for interviews. He makes sure that we have enough for each day. Um, Cameron is my educational champion. Cameron goes through and makes the lecture schedule for the year. He makes sure that we have sufficient faculty to give educational topics. Um, Priyanka is my research person. Priyanka checks in with the fellows on their scholarly activity and also runs our journal club, and those are things that as a PD I just don't have the bandwidth to do. And so early. I found it really important to delegate to those people, um, and they make my life a lot easier. In addition to, you know, pulling off some administrative tasks for me, having this centralized core group of individuals to oversee the program really improved quality. You'll get different perspective on what's going well and what's going poorly, um, and you can make improvements much more quickly. And then finally, it's a win for the faculty too. Having educational leadership roles really empower them. To give you an example, um, this past month, we ran our, our CCC, our clinical Competency Committee. That's a meeting where we go over all the fellows' performance and grade them based on ACGE milestones. So Priyanka ran that meeting. She was responsible. For culling all the evaluations for the fellows, pulling their procedure logs, looking at their ITE scores, um, talking to them about what steps they've taken for scholarly activity, as well as, you know, the, the older ones, um, their career steps, and, and then she, she ran a committee of 10 faculty and, uh, you know, 1 hour and a half hour long discussion. And those are skills that although that's a pretty small meeting, she can take into other parts of her life when she has, you know, her own prevention committee meetings and things like that. And so, um, it's a nice way to give faculty, especially young faculty, kind of early leadership positions. But if you don't have adequate support, program leadership can become very fragile. So you really do need protective time because otherwise PDs and APDs can be at really high risk of burnout. Uh, Institutions underestimate the amount of non-clinical time is needed from physicians to do things like design a curriculum, um, evaluate rotations, or even evaluate fellows. Uh, I'll give you an example from my group. So I was not the original program director. Uh, our, our first program director, Clay Coffin, who's this wonderful human, uh, started the program about 6 years ago. At the time we had our first class was 2 fellows, which I think is like yours. He's also the director of the CICU and runs. The only amyloid clinic in central Texas. So when we had 2 fellows, he was really easily able to balance both of those roles, but as we grew to a full complement of 9, he really didn't have an opportunity to cut back on that clinical time and didn't and didn't really have a ton of protected time to work with the fellowship. Um, and it really weighed on him. It weighed on, you know, his personal life. It weighed on his work life, and he made the decision of like, hey, I just need to step back and give this to someone else. Now, before I took on that role as a group, we actually did a deep dive and say, hey, what do we need to do to make this job sustainable so that we don't have the same thing happen again after. Few years. So we ended up increasing the FTE for the program director and we made some changes with our program coordinator. She was a shared coordinator at first with other programs. We made her a singular program coordinator for cardiology and then we also added additional program coordinators to help offload some of the work for our advanced fellowships like intervention and EP. Um, because if you have recruitment of leadership without support from institutions or practices, it's just really not sustainable and, and poor planning can be fatal. Um, I think we're all familiar when, when hospitals have turnover administration and, and the shake up that can happen with that. Uh, it's very similar for the fellows that PD is kind of the foundation of their program, um, and so when they, when they switch, it's really disruptive to their lives. Uh, in terms of faculty requirements, having a breadth of subspecialties to attract fellows is, is really great. Um, one of the strengths of our program is we can cover core things like, you know, echo, EP, uh, cath, but we also have cardio oncology centers, HCM centers, pericardial centers, a sports cardiology program. Um, because fellows are looking for that broad range so that no matter where they go or what they decide to do, they can get good experience. In addition, experienced teachers really do enhance the product of a fellowship and, and can actually give it its own unique spin. Um, we're a newer program, we're a relatively newer practice in Austin, and so a lot of our faculty have been recruited with a real desire to program build. So when I came, I built the structural imaging program, and our fellows see that. And so they leave their three years of training not only with a really good clinical skill set, but they have all these models that they've seen build programs and start something new, and, and a lot of them have the desire to do that themselves. It's part of. The reason that they joined a new program is to to kind of set their footprint within the training program and so when they graduate, um, one of the hopes we had when we started was that these weren't just fellows that were going to go out and kind of plug and play into a practice they would be joining new groups, going out to new territories and saying, hey, this is my interest not only can I come here and and join you guys, but I can bring this new program and help build it. And not only do they have the skill set from having seen us, you know, go over hurdles and obstacles, but they have a huge group of mentors that they can call back when they run into problems for advice. Um, I also think having, especially in the modern day and age, having fellows within a hybrid academic and private model really gives trainees a nice broad perspective of what careers can be outside a traditional academic setting. A lot of these, um, fellows come like right, my current, my last year's chief fellow Ryan came from the University of Michigan, really. You know, traditional academic program, but now she sees how we interact with patients, what kind of clinical volumes we can do, how we interact with industry, um, how we can do research in a really productive way even outside the confines of things like NIH funding. And so when they leave to find jobs, I think they have a much more open mind of what what the potential they have for going to different places is. I also think our fellows are a bit better at contract negotiation, which is a huge skill that I underestimated when I got my first job. Um, my chief has started two private groups. Um, uh, none of us are on a salary base, and so when our fellows look for jobs, they're actually, they meet with Mark and they, they bring their contracts to him and he can go over the pros and cons and what the potential risks would be, and that's something I never had, you know. You know, as a fellow, and I think a lot of places in in academics, most faculty are salaried and have been for a long time, it's just great, it works for a lot of people, um, but when you're advising fellows for jobs, being able to kind of give them insights on what what good and bad can come from a contract is really helpful. And then finally, all my faculty, even on their worst day with a fellow, find teaching really rewarding. Like it's just so much fun and it brings a lot of excitement to the day. Um, it's just something extra that that's outside of your normal clinical routine. Um, these are a couple awards that that I got that I just took a picture of when I was making this PowerPoint. One's a teaching award, which is really special. The second one's more special for me, our intervention fellow 2 years. Andrew is actually um military based. And so when he graduated, he had spent so much and and I got, I get an honorary interventional sticker because I'm in the cath lab with them for structural imaging for so long, probably like Josh. Um, so when he graduated, he made everyone he worked with in the lab a military challenge coin that was that he designed and he had never done that before, so it's really special. So if you see it around, it says blood, sweat, and heparin. Um, and it was just really fun and then to, uh, to have Andrew go out, he's now a structural interventionist in Washington, and call us back like and tell us all the great things he's doing, like it's just really rewarding. Um, but you need a sufficient number of engaged faculty to not only supervise but meaningfully teach. Um, if you don't have a way to evaluate teaching or even incentivize good teaching, you can get a really variable product and a really variable fellowship experience. Um, overworked faculty can very quickly become disengaged. Um, one of the things when we started is that we had about 9 faculty who were very committed to starting a fellowship amongst a group of about 30 at the time. And so we, we basically had two groups of physicians, one who said, I want to be involved in the academic program, and the other that said I didn't. Again, when we had two fellows, that worked pretty well. Having two fellows and sharing them amongst 9 or 10 faculty, I think everyone could handle the workload. But as it grew to 9 fellows who now not only needed core requirements but needed elective time. Um, putting all that teaching burden on 9 faculty was really difficult, and then they would look and see their partners who were clinically more productive because they didn't have to spend as much time teaching. They were having less procedural complications because as wonderful as fellows are, you will have more complications when you work with them in the labs. Um, and, and they were potentially being compensated more and so it actually created a lot of animosity between the two groups. So we had to sit down as a practice and say, hey, is the fellowship something valuable to us? We decided it was and so we ended up spreading that teaching commitment across the entire faculty, and that's, that's really helped with morale. It's helped with workload, and I honestly think that the fellows have a better experience because they kind of feel like everyone's all in. Um, in addition, uh, physicians are all great teachers. Teaching is something that's, you know, inherently part of what we do and what we see, but we do not have a lot of formal education as educators. So things like giving, you know, constructive feedback or helping fellows deal with the emotional turmoil that can happen when you have a complication, we don't have a lot of experience in doing that, um, for our own faculty. Feedback was a major issue in the early years. When fellows were doing well, I think everyone was really happy to give timely positive feedback. When we had a fellow who was struggling, I think a lot of people just felt a little bit awkward about sitting face to face and being like, hey, you're not doing super well. Some people feel less awkward. The fellows will always tell me that I, I, I'm very happy to tell them that they're not doing. Well, but we have a lot of, you know, very nice people that work with us. But then when that, that fellow who was underperforming didn't hear it all year and shows up at their six month evaluation, and I'm like, hey, you're you're really off pace, it's a shock. And then that created, it can create a lot of animosity between the faculty and the trainees where people think they're talking behind their back and stuff like that. Um, so what I've actually done is when we have our faculty meetings, which are about once a quarter, I spend some time on faculty development. I pull stuff from, uh, MedE as well as even some undergraduate education on things like giving feedback, dealing with complications, so that we can kind of spend some time talking about that, um, and faculty development takes time. I don't know a single person in here who wants another meeting added to their calendar, but it is really important that we spend time not only working on ourselves as clinicians but teachers. And then in part of building a fellowship, you have to really understand your clinical volume and case mix. High volumes create robust training. Um, and it will also attract more applicants and it makes it easier not only to accomplish the COCATs, uh, requirements for training but offer fellows higher levels of COCATs. So this is data from our group that I showed during like our, our presentation. I know you guys are super high volume in a lot of things, um, but one of the reasons I went to the Cleveland Clinic is I knew that no matter what I decided to do or if I switched in the middle of the first year and went from imaging to cath, I would get sufficient volumes that when I left I would be really clinically confident. Um. And so for our fellows within our core curriculum, we can very easily meet things like level 2 echo, level 2 nuclear, level 1 cat, but we can also pretty easily um offer them if they want Level 3 echo, Level 2 CT, Level 2 cath, things like RPVI, um, and so knowing what your case volumes are and being able to um uh kind of create like a benchmark for what fellows can achieve, I think is really helpful in recruitment. And then having multiple sites expands exposure. This is a map of Austin, and next to it you can see our hospitals. Let me get the pointer again. Oops, right here in the middle is where most of our fellows spend their time, which is Seaton, Maine. It's a quaternary care center, huge shock program, a lot of ECMO, high risk cardiac surgery, transplant. We do a ton of valve stuff. And so they spend most of their time working there, but they also go to this hospital right here, which is Del Seaton. So Del Seaton is a county hospital, so it takes care of the underserved population of Austin. It's also a level one trauma center, so they see all the pathology of folks who who really haven't had a lot of medical contact through the years. They also see all the weird and wonderful stuff that comes along with having a level one trauma and the cardiac overlap. So this year, um, Austin Rodeo was in town and this little cowboy, he was like 18 or 19, got bucked off a bull and hit in the chest and got transferred to Del Seaton because he had an episode of syncope and the fellows actually diagnosed an avulsed tricuspid valve, um, transferred him to our main hospital for surgery, and like you just won't see that. You won't, that won't walk into like the super nice, you know, part of Austin where Seaton, Maine is. Um, in addition to working at Del Seaton, they do spend, um, certain electives such as Ch down at our satellite centers. So down here is a place, whoops, down here called Kyle, um, and so Kyle is a community hospital that's run by, uh, it's our group, but really great private practice cardiologists, um, who work in a very different way than we do. So when the fellows do cath at Seaton, Maine, they see, I was just talking to Matt Lott of a lot of surgical turndowns, high risk PTIs, CTO, left main interventions. But then they go down to Kyle and they'll do like 10 type A lesions, see 8 consults, and do 4 TEs. And so it just kind of gives them a different breath of like what a cardiology job can be like, and then they can figure out what they want to do. Do they want to work in like a high risk referral center or do they want to be out in the periphery where you can have a really successful job um and do really, you know, high level things, but it's just a different patient population. But borderline case volumes can risk noncompliance or even force fellows to compete for cases, so you have to be really honest about what your volumes can do. And in addition, having a good case mix is important. It's wonderful if your hospital does 2000 PCIs per year, but if you don't have on-site things like on-site CT, on-site MRI, on-site PET, you may actually lose out on valuable applicants as they evaluate what electives and what options they have to achieve competent training at your program. Um, in addition, you know, having a lot of sites can improve their exposure to different teachers and different pathology, but having too many sites can dilute teaching quality and can actually sometimes lead to dangerously low supervision. So you have to have a method, even in those peripheral sites of evaluating teachers and making sure you have oversight of the rotations that go on there, um. Interestingly, very high volumes can also blur the line between service and education. If you have a small fellowship and huge volumes, um, it can actually overwhelm the fellows really quickly if they feel responsible for all those patients. And then paradoxically, one thing we ran into is we were again super high volume and especially in the first two years where we only had 2 fellows, you couldn't have a fellow attached to every case. And so. can feel sometimes a little superfluous to the process. Like, I can finish a T 100 times faster if I don't have a fellow than if I have a fellow. Um, and so sometimes they feel like they're bothering you if you're, you're in there, if they're in there with you. Um, and so they, they might feel like they're really not integral to the workflow, and that can really chip away at how engaged they are in their training. And then every now and again you will get a fellow who will take advantage of the situation and skip out on stuff if they don't feel like they're crucial to completion. So whatever your whatever your workflow is, you have to make rotations where they are really integral to the process. Um, Educational infrastructure, um, beyond just having a great faculty is really important. Having a strong lecture plan, which includes things like case reviews, echo and EKG teaching, M&M's can really build a strong academic foundation. This is a sample from our, our lecture schedule this year. So Cameron goes through and creates a whole list of topics that's grouped by a kind of theme, and then he assigns it to a. Mix of either attending uh lead or fellow giving lectures and he does that for the whole year. Um, Priyanka sets aside some time for journal clubs, so journal club is every month and she actually pairs fellows with attendings to go over, um, landmark articles and then we do journal club actually after hours and attendings house, um, with, you know, food and drink and stuff, and it's really fun for the fellows and the faculty like the discussion too. In addition, having structured structured reviews of the fellow's performance is really vital to helping fellows meet benchmarks. So programs will always have a required twice a year clinical competency evaluation. That's something that GME requires. But in addition to that, I actually meet with the fellows one on 14 times a year, um, just because I realized if they're getting feedback in January 6 months have passed, and they have not really heard what's going well or poorly, and then again they get, you know, another session in July and it's like, well, I'm about to graduate. So I meet with them intermittently throughout the year and I actually have the fellows send me their own sets of goals at the beginning of the year, so that they have things that they're working on that that's purely from them and things that they're working on that that I've given them. And then finally having interdepartmental communication even outside of cardiology really strengthens your educational product and can bring you new ideas. So I meet every other month with the PDs from all the medicine and medicine subspecialties and I meet um with the broader GME community once a month, um, just to kind of talk about things going on within the UT system that are um. Happening and so that has really helped us. Our CCC meetings were like horrible. They were, they were like 4 hours. It would take forever. We would have a lot of energy when we ran through the 1st 2 fellows, and by the time we got to the last one, we were like giving them 5 minutes. Um, and so, uh, this year, the Department of Internal Medicine, which is a much larger program than us, presented how. They run their CCCs and I was like, oh my gosh, why did no one ever tell me this before? So they make these really nice slides where they pull all the information in and we actually ended up using that as a template for how we ran our program. It made it a lot more efficient. It actually made it a lot more effective, and I had faculty come back and tell me like, why haven't been doing this for years, and those are ideas I would have never gotten if I didn't work with them. But having a good infrastructure is hard. It needs consistent effort from multiple people. Again, the administrative burden of this can be really high. I heavily suggest that all fellowships make a handbook of some kind, and there are lots floating around as examples, but programs really need policies to cover everything as simple as leave, rotational goals, what is expected for fellows based on their PGY year. Um, and those policies need annual revision and maintenance. When we started our handbook, it was probably 20 pages, and it was like, hey, you know, you're going to make your schedule. If you have leave, you call the program director. It's about 100 pages now. Um, it includes things like educational resources for them for each rotation, what they're expected to do, you know, based on their year, um, for competency so that we can kind of say, hey, you're ready to go on the next step. Um, and, and even something as simple as putting a chat, a chart of COCAT's requirements at the end so that they really know whether or not they're on pace for achieving their levels by graduation. And so this really requires commitment from both the faculty. Like it takes a lot of time and every year our rotation directors go back and redo and revise their handbook sections, but also the institution because to allow faculty to have that time or have meetings to like figure out what are better ideas, institutions, including hospitals and practices have to support that. Um, and then you also need a skilled program coordinator. A program coordinator role is huge. Like at Cleveland, we had this woman named Lois, and like Lois ran the cardiology program at Cleveland. Um, I have Tommy, Tommy's wonderful. Tommy came to me from, um, having years of experience in the department of internal medicine. And so it's been really nice, you know, me being new in this role, to have someone to have a lot of experience to be like, hey, I think that's a bad idea. Don't do that. Um, and, and, but I've seen other departments that have pulled program coordinators from like other parts of the hospital, and, and you really need at least a, a few core people amongst the program coordinators who had prior experience to be able to really help PDs and APDs. Um, research infrastructure is important. Uh, scholarly activity is important for fellows. It helps increase the program's publication visibility. If you're interested in presenting at national meetings, it helps broaden that footprint. It also lets fellows network across institutions, make connections, also learn how to work with industry, which is so important in our lives. Lives. Um, for us it really provides fellows for models of how you can incorporate research into a busy clinical practice. Like this idea that you have to be someone who spends like 3 days in your office or in a lab doing research like isn't really true. You can do a lot of stuff and and be almost 100%, you know, clinically busy. And then it also helps engage faculty in mentorship. They work more closely with the fellows on projects. It kind of creates new channels for relationships outside the clinical space, and it opens doors to grant funding. So just this year, our EP fellowship got a $15,000 grant from Abbott to do just pure research, which has been great. But, um, research like everything else requires a lot of support, so you need um IRB support to help the fellows access to data and analytics help, and fellows need guidance. They need some sort of framework or some sort of way to access mentors, access projects, and also have check-ins to make sure they're making meaningful progress, um, because if you don't do that and you just tell a fellow, you know, think of a question and go for it, the likelihood that you're going to have something meaningful at the end of 3 years is very small. Um, and then, uh, having limited mentorship can really bottleneck the process. If you have only one or two faculty who are willing to work with fellows on projects, you can one, really overload those faculty, and 2, as your fellowship grows, the fellows' ability to access those two people can become really challenging. And so, it's important for institutions to really go out of their way to build a sustainable research pipeline for their trainees. Um, the next recruitment strategy. Recruitment for a fellowship is huge. I, I, I see my job a little bit like a college football coach. Like, I spend probably July through September with my almost entire focus on recruitment. A really structured recruitment can boost visibility and attractiveness of programs. It will help you get better. People. So we do our recruitment in person, being a small program that doesn't have a huge national name. Like if you're Cleveland Clana, you can do your, your recruitment online. Everyone knows what they're getting. But if you're the University of Texas at Dell, a lot of times, you know, the places they're coming from haven't heard of that program. So to see what we do in person, meet our fellows, meet our faculty has been hugely important. Um, you will have a huge number of people see your program when you, when you enter into recruitment. We got 800 applications this year that we then called down to 70 people that we invited. Not a single one of those 70 turned down an in-person interview, and then we were able to, um, winnow down that 70 to a ranked list of which we, we got three wonderful candidates. One is an internal chief, one is the chief from the University of Kansas, and the last one is coming to us from Baylor. Um, and faculty feel more engaged when they're involved in recruitment. They want to be part of building that culture of your program and meeting the people that they're going to work with, um, and good recruitment can really attract, uh, high quality mission aligned fellows, and, and you really want to recruit not only for a good name or good scores, but a fellow that will really fit with the strengths of your program. So when I do my recruitment, this is the slide I show. So, these are kind of the core pillars of our program. We want fellows to have access to experience. It's a small program, so you get a lot of 1 to 1 mentorship. It's like a private school. There's like way more faculty than there are fellows. Um, and then we have a lot of flexibility within our curriculum for the fellows to really leave with training crafted to their goals. So like my two fellows that were applying into EP this year had done over 6 months of EP by the time they left. Um, and then I show this picture because like this was within my first year of working, and here's Sergio, who's now one of our faculty doing the tea for a Watchman, and Sergio and Priya are our first two fellows, and that's Priya doing the whole Watchman. Chris Hinesman, our EP standing next to her. I mean, we basically stood next to them and they did the whole thing as a 3rd year fellow, which is, is pretty huge, right, as a general cardiology fellow to be able to do a Watchman. And, and when you can offer something like that, I think it, it speaks volumes and you're going to get people who want those qualities in a program. Hm, let me see if I find anything else. But like everything else, recruitment takes time and money. My schedule in September is a nightmare. I take 4 to 5 days where I completely cancel all my clinical work, um, to interview applicants, and I, I meet every single applicant that we interview. I try to make that burden not as high on the faculty, so we never ask anyone to give more than 2 half days, um, during recruitment season, and it also takes money. So like fellows come with CMS funds, but that won't cover pre-interview socials, lunches, you know, all the things you have to buy to make your fellowship like folders look nice, um. And so it's a, it's a heavy burden that you have to plan ahead for. Um, effective interviewing also requires coaching. You want to make sure that the faculty, one, are asking questions so that they're getting meaningful feedback from the fellow or the applicants. And then 2, that they're even the most well-intentioned person can ask a question that's not really kosher during interview season, and it. Make make the program seem like they're either discriminating or trying to find something out about the fellows' personal lives. In addition, faculty need help to help standardize candidate attributes and also evaluate um fellows. So I actually have a math formula where I plug in all the objective data from their application. I, I kind of stole it from the Yale IM program director. Um, and it weights things like step score, the type of the, the level kind of a residency that went to a top tier versus middle tier versus a community hospital, um, and then, uh, I also, I also put in a score based on how each of our, uh, interviewers, uh, graded them for the day. And so that gets put into a math formula that spits out a number at the end and that's how I make my initial rank list that we then go back and talk to the faculty about and they switch stuff around. Um, but, uh, the other thing I did was I made a, a grading rubric. AI is very helpful with these things, by the way, um, so I made a grading rubric so that the, the faculty had something that they could reference back to when they were talking to applicants to say, hey, is this a high quality applicant, a low quality applicant, or middle of the road. Um, and so all of that takes work, uh, faculty, if you get them involved and they interview candidates and then they feel like their feedback gets ignored, you will not get that faculty back to interview next year. And so in order to keep a good group of people that's again engaged and invested, you really have to, to take feedback, um, from the people who did your interview. Interviews. So I actually meet, you can see this is my schedule. I meet with the faculty at 4 p.m.s easy. It's like a Zoom call or I'll call them one on one to get feedback from, um, their day, and then I will also, once I make my rank list, we have a big meeting with everyone who interviewed applicants, and we go over the rank list and that way they can advocate for people or say, oh no, no, I think this is a bad idea. Um, and so like we all had one person this year who were like, we would rather not match than have this person match with us, and I left that that applicant off my rank list, but that was a unanimous decision from all of us. Um, and it's nice to kind of go into your rank list, like all, all behind who you're going to match and we ended up, we, we didn't go lower than number 7 for our list this year. Um, and then finally, overpromising your program to applicants can, can really damage your, your reputation. You want to make sure that whatever you're telling them on that day you can deliver, because if you promise things to applicants and they get here and it's not the reality, that will spread really quickly and really damage your reputation. So programs have to be really honest about their strengths and weaknesses. Um, sustainability training programs really do help foster an institutional culture and, and make an institution stronger. So improving the experience for fellows is really a unifying force and can help spur change for the better, you know, within a program. So, uh, echo standardization, echo report, I'm an imager, so echo reporting standardization, you can imagine amongst a group of 40 cardiologists, high variability. Uh, we realized very quickly when we were reading with the fellows that we need to have some standardized template for reporting so that they are doing the right things and coming out kind of really well trained, and, and that made us all kind of as a group say, hey, no, it's OK, we can standardize ECA reporting and it's been one of the great things that happened and if we hadn't had the fellowship, it wouldn't have gotten highlighted and we wouldn't have that like just group push to be able to do that. And then growth can also help develop novel educational practices as we trained the fellows, we became more and more involved with IM training. More of those IM residents wanted to become fellows. We wanted to make sure they were good at cardiology, and we actually realized they were performing poorly in cardiology, not only through their clinical rotations because they weren't getting enough experience, but their ITE scores were like the 30th percentile for cards. And so we actually created a novel service. That's a co-management between cardiology and IM where um where they basically get triaged only cardiology patients and then a cardiologist and an IM attending do kind of co-rounds with them each day and that's not only improved their clinical care, but if you look at their ITE scores since that that rotation's been in place, they're now above the 90th percentile for scoring. And, and this year they, they used to never have anyone apply to cardiology. They had 6 really strong applicants this year. They all matched, so it's been wonderful, um, and so that that actually got written up as like a project and has gotten presented at educational conferences and and gotten awards nationally, which has been fun to see. Um, having fellows makes you want to innovate and stay on the forefront of advancements and so it furthers the subspecialty pathways that practices will create. Um, and, and it can really, uh, have a push to make those centers of excellence, um, and then when you have fellows remain on as faculty, it creates a really nice pipeline of educational leaders who, um, not only have insights into their training program but are really happy to kind of give back and improve it. But a sustainable program requires a lot of ongoing monitoring and vigilance, um, so not only do you have to kind of continually revise your practices, um, you are responsible for things like the annual ACGME survey. Uh, when you have a small program, your denominator is very small, and so if you have one concerned voice within that program, it can leave a big mark on your ACGME survey we. Actually realized that within the first few years we were getting these surveys back. Our fellows seemed really happy and then we were getting survey results back. It's like, wait a minute, you're not happy? And so what we actually did is that I created a survey that goes, it's anonymous, it's internal. They can't, it's not multiple choice, so they actually have to write out a sentence, and they, they have to tell us, you know, what's going well. I send this out on the early end, so usually it goes out like. I send it out now it usually goes out in like December and so then we have a chance to kind of have a town hall with them, talk to them about stuff. Sometimes they realize the things they're concerned about are not actually concerns, right? Like it's like you guys say we're not doing this, but like we are doing it and then they realize it, um, but, but sometimes there are real problems and you can respond and course correct on the early end, which I think they appreciate and then when they take a formal survey they at least know that you're trying to make things better. Um, in addition, not preparing fully for future growth with regards to things like clinical volume, teaching capabilities, and administrative support can really kind of tackle a program, um, and so you not only have to plan for your own fellowship growing, but if you want to start things like an advanced fellowship, intervention EP, figure out, hey, you know, are those, those case volumes of those individuals going to interfere with the training of our general fellowship, um, because if you don't grow and change, uh, even programs that have a good launch can have a high potential to stagnate. Designing a curriculum. A strong curriculum is probably a program's best asset. So well rounded curriculum turns out well rounded fellows. So you need to make sure fellows have all the core things that they need to become a good cardiologist. But the other fun thing is that programs can really decide on their own pillar rotations. So for us, that was CICU. We all felt very strongly that CICU was probably the heart of. So of a fellowship, it's where fellows can take all the various skills they build and things like EP, echo, cath consults and kind of put them all together on, on, on the sickest of patients. Um, so because of that we made that a really core part of our training. So they all do at least 2 months during the day in the CICU and each of them actually takes 1 overnight call per week in our unit. Um, and that's because I didn't want the fellow doing CICU in July and then never doing it again until the next year and losing all those procedural and clinical skills. And so they get these little intermittent bolus of CICU throughout the year. So even if they're an echo, they, they feel really good putting a PA catheter in or, or popping a balloon pump in, um. The uh, the other good part of that for us is that that has created really wonderful CICU coverage. We now have a really robust 24/7 in-house covered CICU, and everyone in the hospital knows, the nurses know, the doctors know if there's a cardiogenic shock patient, they call our fellow first. The fellow handles it and it's kind of done from there. And so it's been a nice win-win. They get really good training and we have a service covered really well. Um, in addition, continuity clinic is important. It provides fellows with a sense of ownership and also gives them really good experience in managing an outpatient panel. Early on, we had our fellows in our own private clinics, and the fellows on their own actually said within the first year, Hey, we love working with you guys, but these are 100% your patients and they don't feel like ours. So we actually pulled them out of our clinic and they, they now have their own panel of patients. that they see as part of a group called Community Care, which is uh the Travis County health plan and so they see those patients and they see them their first year until they graduate. It's a panel of patients that they grow, they can grow them from inpatient consults if they see them in the hospital. Um, and if that patient needs a cabbage, the fellows are referring them to the cabbage and talking to the surgeon. If they need a procedure, they're, they're setting them up. They're referring for tier, they're the ones calling me and talking to me, talking to me about, you know, what they think that the patient needs, and it's really fun actually to, to see a patient in the hospital and you ask them who their cardiologist is and they'll name one of our fellows, um, and then finally having electives allows fellows to explore kind of their subspecialty interests and professional interests, um, kind of as they, they grow in their training. So we have a couple of specialized pathways. Specialized pathways are something that I, I hope to grow even more, um, during my tenure as PD. So we have one really nice one set up for imaging where, um, one fellow a year we can tailor their curriculum so that they get level 3 echo by the time they graduate. In addition to having kind of all their echo numbers, they give. Lectures on advanced echo topics. They participate in our network-wide QIQA with with our sonographers, and they're also involved in our network imaging meetings when we're talking about things like equipment buying and stuff like that. They get extra training and structural intervention. We also have training to certify 2 fellows a year in Level 2 CT. Um, so that they can go out and practice. These are things I want to grow. So like I had two fellows that I realized when I was writing their PD letter do 6 months in EP. I was like we could very easily create an EP subspecialty pathway. And these are all things that when you're recruiting are really attractive to fellows who come in. A lot of them come in not knowing what they want to do, but you're going to have a handful that really do. And so it's, it's a nice thing to offer. And we also have a really nice global health pathway. We have two cardiologists who are really heavily involved in global health, one in Kenya at Eldarat and one who goes and does a program in Mexico. He's one of our advanced heart failure doctors, um, and so we have had fellows who come into training with that as an interest. They've done it before during residency. And so we're able to offer one a year to spend a month between their 2nd and 3rd year, um, to, to go abroad to one of the programs and and work with our doctors down there. um, we're again hoping that some of our endowment funding can can do more trips and electives like that if, if you have a fellow with a strong interest. But designing a good curriculum can be complex. You have to be very mindful that you are, you can use the fellows to help cover clinical needs, but you have to be mindful that you're not overwhelming them in certain areas of the hospital. Our fellows known. Don't at all mind that they do one, you know, call a week with our ICU, but I have seen it talked about in recruitment and things like that. People are like, oh, they have a terrible call schedule, um, things like that. And so you just have to be a little bit mindful about where you're putting them and, and. And what you're doing for coverage needs and that it's not impacting their education. Also, schedules need oversight. Our chief fellows do our schedule and what they think is important doesn't always align with what we think is important, especially when you have people call out and are sick. And so there has to be a lot of back and forth between either the PD or another faculty member and the fellow schedule. Um, if you have underdeveloped electives, so like you. You have fellows who want to pursue something like let's say sports cardiology and you don't have that um available, it can create gaps and fellows may actually need to go to other sites to pursue that, which is not a, it's not a huge deal, but it's again an additional resource that you're going to have to expend in time of the fellow away from the program and I think one of the most important things is the same model won't work for every program. So when we started, a lot of us had trained at the Cleveland Clinic. Um, and we said, hey, we loved our training. Let's just recreate that here. Well, the Cleveland Clinic has about 50 general cardiology fellows. It's like an army of fellows. We had 2. You can't do the same thing, and we very quickly learned that was not a feasible pathway to just emulate the training programs we, we had been a part of. The good thing is a lot of fellows will really voice what's going well and what's not, so you'll get a lot of feedback from them. And your other faculty. And so because of that, these curricula need frequent revision. So every year we go back to the rotations, the rotation directors, and we say, hey, you know, this is the feedback we got, this is what's going well, this is what isn't, and we try to make things better. And I think fellows really appreciate, I mean, they understand that everything's perfect. I'm very honest with them but we're a new program, like things change and grow all the time, but if you are, if you are honest about your commitment to make changes when changes need to occur, I think fellows really do appreciate that. So this is the last part. You're almost at the end. So this is just a decision roadmap that I like to use as a step by step plan for creating a fellowship. You guys are probably halfway through this roadmap, but it's kind of good to see. So phase one is kind of the readiness phase. This should ideally occur like 12 to 18 months before you submit your application. This is when you look at your department and you do a volume analysis. You make sure that all the faculty are aligned. I really try to emphasize all, um, when you only have partial faculty alignment, things can become challenging and so. Having everyone kind of be all in is really useful. Um, this is where you can kind of set aside what your institutional resources will be, what money you're going to get from CMS, what needs to come from external funding, what potential external funding sources need to be gathered. You can draft your rotation grids to make sure you have adequate coverage, um, and then you can identify leadership. The next phase is the building phase. This should occur again before the application is submitted, a little bit closer, 6 to 12 months. This is when you can finalize your curriculum, create a structure or at least an outline for your educational conferences, start making those policies for things like a handbook, and then also prepare that ACGE application and prepare recruitment. I, I think it's very important to do a lot of planning for recruitment because the more organized your recruitment is, it is just so much more efficient and less stressful when you go through it. And then the final year is your launch year, and so that's actually your one. And so during this year, I recommend kind of making an orientation not only for the fellows, but even for the faculty who are going to be involved, and you need really frequent feedback loops from both the institution, the faculty, and the fellows, so that you can figure out what's going well and what's not and can course. Direct, um, because no matter how well prepared you are, operational issues will occur during this first year, and the faster you can react to them in a successful way, the better you'll be. And then you also have to prepare for those usual things like ACGME site visits, which they'll do kind of early on in a structured basis when you're first starting. So what about the rewarding part? I was making this talk and I showed it to my chief, and he was like, don't scare them off of having a fellowship. Um, but, but having the fellows really is probably the best part of my day. When I looked for a job, I had 3 non-negotiables. I wanted high volume because I like being busy. I wanted to do structural imaging and I like being in the lab, and then I wanted to work with trainees, and I really don't regret having that last part be part of my job. Um, this is some of the places that our trainees have gone to. Like they've done these great advanced fellowships. A lot of them have stayed on, or not a lot, a few handful have stayed on as faculty at Dell, and one of them has a podcast. It's like super successful. And so it's really fun to see them go out into their careers and, you know, call you and ask for advice or even say, hey, you know. You taught me this, and so like I, I'm making, I'm now making my fellows do this. Um, and so it's really a rewarding process. I think the whole hospital loves the, the, the, my hospital loves my fellows way more than they love any of the faculty. Like my cath lab loves my fellows, my EP lab loves the fellows. Like they're just a really fun energy that they bring into this space. Um, and so, uh, the other thing my boss told me is the most important thing you can do is have a positive impact on others because really we are what we leave behind. Um, these are some pictures from our graduation. We always invite not only all the faculty, but like in the bottom corner, this is Dave. He, he's like one of our EP staff and his wife, and like they all, they all are a part of building our fellow. Like I know we all look back and remember nurses or techs that really were an integral part of us becoming doctors. And so it's a really nice, you know, collegial culture and the fellows are kind of the heart and soul of our practice now, which is fun. So just some takeaways, um, a fellowship can be great. It will amplify your growth, create a nice culture within your institution, and really solidify your academic identity, um, but success requires very careful planning, good infrastructure, aligned faculty and institutional support. There are very real challenges, but, but they can be manageable, and a good program that reacts to things intentionally and not reactively can be very successful, and you can have a very rewarding, um, fun, successful training program. So, thanks. Any questions? Published December 16, 2025 Created by
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