Changes and challenges in cardiology trainingBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7269 (Published 08 November 2012) Cite this as: BMJ 2012;345:e7269
- David Holdsworth, specialty trainee year 5 in cardiology and general medicine
David Holdsworth reports on the highlights of the 2012 survey of the British Junior Cardiologists Association
Cardiology, in common with other medical specialties, has experienced a considerable overhaul in the past decade. Increasing complexity of cases and the growing variety of diagnostic and interventional techniques have led to a necessary restructuring in the delivery of cardiology services. As a result, there has been a move away from the often singlehanded general cardiologist model to a more team based subspecialised approach, which is reflected in a decrease in the demand for general cardiology appointments.
In addition, the NHS has experienced huge changes during this period, which have had a major effect on training and service delivery in all medical specialties. The NHS Plan,1 published by the Department of Health in 2000, called for 1000 more medical school places, in addition to the 1100 that had been put in place since 1997. Overall these moves were intended to increase the number of medical graduates by 40% over eight years (1997-2005). Consultant posts have not increased to the same degree, however, and all specialties are now producing a greater number of qualified trainees, many of whom struggle to find consultant appointments.2
The direction to increase the numbers of trainees led to secondary reform of postgraduate medical training in 2005 under the auspices of Modernising Medical Careers. During this period, two new curriculums for cardiology training were introduced (in 2007 and 2010).34 These were based on a new model (one year shorter than the previous specialist registrar system) that split specialty training into an initial three year period of core general cardiology—including a summative knowledge based assessment—followed by two years of modular subspecialty training. Training is now more transparent, reproducible, and competency based.
The current cardiology training programme has to negotiate a tension between the requirement for high numbers of procedures, a demonstrably high standard of competence, and rapid completion of different modules of training, all within the constraint of limited weekly hours. The difficulty of achieving this balance is compounded by general on-call requirements.
These changes in healthcare provision and the structure of training are likely to have affected cardiology trainees. Few data are collected nationally, however, to provide information on the changing subspecialty choices of cardiology trainees, their experience of training, and their views on their prospects of a consultant appointment.
British Junior Cardiologists Association’s 2012 survey
The British Junior Cardiologists Association was formed in 2001. It comprises a network of all UK cardiology trainees and represents these trainees to the British Cardiovascular Society, the National Cardiology Specialist Advisory Committee, and on all national subspecialty groups.
Since 2004 the association has conducted five surveys of cardiology trainees to measure their attitudes towards, and experiences of, specialty and subspecialty training in the context of Modernising Medical Careers and a changing NHS. The specialist advisory committee and the British Cardiovascular Society scrutinise the survey findings, and the specialist advisory committee would like to make completion of the survey a part of completion of the annual review of competence.
This year a link to an online questionnaire was sent to all trainees on the association’s database. The response rate was 35% (261 of 745), and the respondents represented all deaneries and years of training. This response rate demonstrates the positive engagement of cardiology trainees—through the association—with their trainers, commented Jim Hall, chairman of the cardiology specialist advisory committee. “Cardiology trainees and the BJCA [British Junior Cardiologists Association] are helping to shape national strategies through structured responses, not just anecdotes,” he said.
The survey has 84 questions across 10 different domains, such as career paths, study leave, and working patterns under the European Working Time Directive. But it is the results from the domains on subspecialty training and consultant job prospects that are of particular interest.
The intended subspecialty choices of trainees have changed since the survey was first conducted in 2004 (fig 1⇓), reflecting the expansion of non-invasive imaging (specialist echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging) and device therapy (implantable cardiac defibrillators and cardiac resynchronisation therapy devices). Conversely, the proportion of trainees seeking coronary intervention as a primary subspecialty has fallen over time, from 44% in 2006 to 25% in 2012, possibly reflecting the perception that the subspecialty has completed its considerable expansion and that fewer consultant posts will be available in future. Another factor could be an aversion to on-call primary percutaneous coronary intervention rotas.
The other trend shown by these figures is the progressive fragmentation of cardiology into its component subspecialties. In 2004 more than half of trainees were intending to pursue either interventional or “general” cardiology; now 84% of trainees are divided among five subspecialties, which each represent between 11% and 25% of trainees. “General” cardiology has shifted from a popular primary subspecialty to the most popular secondary choice (fig 2⇓), reflecting a growing trend for trainees to adopt and develop at least one secondary subspecialty.
The survey results indicate a clear national consensus on the cardiology subspecialties in which it is most difficult to access training. Regrettably, cardiac imaging, the subspecialty preference that has shown the fastest rise over the past eight years, is the principal area where trainees have difficulty. More than a third of trainees cited cardiac computed tomography and cardiac magnetic resonance imaging as areas in which it is difficult to get adequate training. Paediatric cardiology and adult congenital heart disease are other commonly cited areas of difficulty (fig 3⇓).
The survey showed that the median time between graduation from medical school and starting cardiology training is six years (range 4-17). The minimum time for completing specialty training in cardiology is five years, although two thirds (66%) of trainees have completed or are planning research, which adds a minimum of two years. Therefore the typical trainee attains the certificate of completion of training (CCT) 13 years after graduation. A considerable number (28%) of trainees actually took eight years or more to successfully start specialty training and therefore 15 or more years to reach CCT.
The opinions of the current cohort of trainees on their prospects of a consultant appointment is striking when viewed in the context of this long period of training. Around two thirds (60%) believed that their prospects of gaining a consultant appointment were worse than two years ago, whereas only 5% thought that their prospects were better (fig 4⇓). Most (89%) did not believe that there would be enough consultant posts available over the next three years, and nearly half believed that the creation of a post-CCT junior consultant grade was probable (32%) or inevitable (17%).
The survey asked trainees what they planned to do if they did not get a consultant appointment after achieving their CCT. Forty per cent would seek a fellowship and 21% a locum consultant post, but a quarter (25%) said that they would seek work overseas (fig 5⇓). A majority (54%) cited “subspecialty” as the key factor in seeking a consultant post, with “location” (29%) and “good working relationship with colleagues” (17%) also well represented. Only one person (0.4%) listed “remuneration prospects” as the chief driver.
These data, from a regular survey of UK cardiology trainees over eight years, reveal a specialty in flux that is remodelling into an increasingly diverse array of subspecialties. This change reflects a growing range of both diagnostic (cardiac computed tomography and cardiac magnetic resonance imaging, nuclear, specialist echocardiography) and therapeutic (device implantation, radiofrequency ablation, percutaneous valve intervention) techniques that demand “superspecialist” expertise to maintain quality and patient safety. Interventional cardiology is less dominant as newer subspecialties expand.
Certainly some gloom exists among trainees about the prospect of a consultant’s job at the end of up to 18 years of training. Medical student numbers increased by 40% from 1997 to 2005. Allowing for five years of undergraduate medical school teaching and 9-13 years of postgraduate training to CCT, a “bulge” in doctors seeking consultant posts can be anticipated between 2011 and 2023. Cardiology trainees seem concerned about the emergence of a service provision junior consultant grade to accommodate this bulge, and many seem determined to escape into fellowships or work overseas.
The development of new services, diagnostic and therapeutic, will offer the opportunity for consultant expansion. The most recently published census data show a 11.3% expansion in consultant posts between 2009 and 2010,5 albeit after an apparent contraction the previous year. The specialist advisory committee believes that there will be a 5% annual increase in cardiology consultant numbers over the coming years—enough to employ those who are now coming up to CCT.
The future of cardiology is one of increasing diversity and superspecialisation. It seems that trainees may be cautiously optimistic that within an evolving specialty there will be jobs to go to.
Competing interests: None declared.