The Path to a Match for Interventional Cardiology Fellowships

The Society for Cardiovascular Angiography & Interventions has started a fellowship match, and here's an article describing the familiar marketplace failure that led to that decision, involving unraveling of application, interview and appointment dates, with the resulting congestion and exploding offers, and the process of reaching sufficient consensus to move to a centralized match ( to be run by the NRMP).

The Path to a Match for Interventional Cardiology Fellowship: A Major SCAI Initiative  by Douglas E. Drachman MD, FSCAI (Chair) a, Tayo Addo MD b, Robert J. Applegate MD, MSCAI c, Robert C. Bartel MSc, CAE d, Anna E. Bortnick MD, PhD, MSc, FSCAI e, Francesca M. Dea d, Tarek Helmy MD, MSCAI f, Timothy D. Henry MD, MSCAI g, Adnan Khalif MD, FSCAI h, Ajay J. Kirtane MD, SM, FSCAI i, Michael Levy MD, MPH, FSCAI j, Michael J. Lim MD, MSCAI k, Ehtisham Mahmud MD, MSCAI l, Nino Mihatov MD, FSCAI m, Sahil A. Parikh MD, FSCAI i, Laura Porter CMP d, Abhiram Prasad MD n, Sunil V. Rao MD, FSCAI o, Louai Razzouk MD, MPH, FSCAI o, Samit Shah MD, PhD, FSCAI p, Adhir Shroff MD, MPH, FSCAI q, Jacqueline E. Tamis-Holland MD, FSCAI r, Poonam Velagapudi MD, FSCAI s, Fredrick G. Welt MD, FSCAI t, J. Dawn Abbott MD, FSCAI (Co-Chair), Journal of the Society for Cardiovascular Angiography & Interventions, in press.

"Abstract: The field of interventional cardiology (IC) has evolved dramatically over the past 40 years. Training and certification in IC have kept pace, with the development of accredited IC fellowship training programs, training statements, and subspecialty board certification. The application process, however, remained fragmented with lack of a universal process or time frame. In recent years, growing competition among training programs for the strongest candidates resulted in time-limited offers and high-pressure situations that disadvantaged candidates. A grassroots effort was recently undertaken by a Society for Cardiovascular Angiography & Interventions task force, to create equity in the system by establishing a national Match for IC fellowship. This manuscript explores the rationale, process, and implications of this endeavor."

"over the past several years program directors and candidates found that the process has devolved, with wide variation in application timelines and on-the-spot offers, which disadvantage candidates and programs looking to interview a range of applicants.

"The pressures and unfair features of the existing system were further fueled by the transition to virtual interviews related to the COVID-19 pandemic. With logistics of travel no longer a consideration, programs could commence interviews nearly immediately after the applications became available. This led to more candidates being interviewed in rapid succession, and a system evolved in which programs quickly assessed candidates, offered positions, and applied pressure for candidates to accept offers or be passed over for other candidates.

"In response to the shortcomings of the current system, members of Society for Cardiovascular Angiography & Interventions (SCAI) were inspired to lead a grassroots educational campaign to organize IC program directors and the broader interventional community to commit to a regulated “Match” process under the established National Resident Match Program (NRMP). This manuscript provides an account of how this process unfolded and how a Match for IC fellowship was ultimately created.

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"From the applicant’s perspective, the lack of a structured timeline for the application process required candidates to make career decisions early in the first year of cardiovascular disease training and to compose their application materials 2 years in advance of starting IC training. With ERAS open to application submission in the fall of the second year for the December release to programs, fellows had limited time on clinical rotations to determine their interest and aptitude for IC. Additionally, letters of recommendation, written at this early stage, risked not being fully reflective of each candidate’s capacity to improve and develop the technical skills and clinical knowledge important for success in the field. There were other disadvantages to candidates in the existing system. Fellows at programs with an IC fellowship had an advantage of securing an internal spot but were often pressured to limit their exploration of the opportunities at other programs, potentially disadvantaging them in the long term.

"Another problem with the existing system was that the pressure to recruit candidates on a tight timeline limited the opportunity to interview applicants from a wide variety and diversity of programs, potentially reducing the ability to recruit underrepresented candidates from varied programs. Despite an overall increase in the diversity of physicians entering the workforce,11 there has been little change in the applicant pool for IC over the years, with fewer than 5% of applicants self-reporting as Black race or Hispanic ethnicity and only 10% identifying as women.12

"Competition among the programs, each vying for the seemingly strongest candidates, degenerated into a system that favored quick decision-making on the part of programs to offer positions as early as possible. The influence of the COVID-19 pandemic in 2020 and 2021 negatively impacted an already high-pressure application process, compounding its many weaknesses.13 Fellowship interviews were hosted virtually rather than in person, which enabled candidates to interview at a greater number of programs without the need to travel. In addition, the virtual format accelerated the tempo of an application process that was already felt to be too fast, resulting in an increase in so-called “exploding offers”—offers that required the accepted candidate to respond within a very short timeframe or risk losing the offer. This practice placed significant pressure on candidates to make quick decisions, often forcing them to determine whether to accept the offer from 1 institution before having the opportunity to participate in interviews with—let alone see and evaluate—other programs or fully understand the ramifications of accepting an offer on their personal lives. At the same time, the accelerated timetable left many programs scrambling to identify applicants, as the number of available candidates diminished rapidly due to applicants accepting time-sensitive, exploding offers.

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"As with other national efforts of this magnitude, the path to develop consensus in favor of a Match was not without challenges. There were several program directors around the country who strongly opposed the institution of a Match. These were well-regarded academicians and clinician educators who expressed very sincere concerns about the impact on fellows in their programs. The members of the SCAI Match Task Force addressed as many concerns as possible, providing the information necessary for each program director to make the best decision for their institution. A minority of program directors remained opposed to the initiative or did not engage with Task Force members despite multiple attempts to be contacted.

"The Match campaign proved highly effective, and by November 2022, the 75% threshold of programs and positions to implement the Match was met

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"As the sponsor of the Match, SCAI considered the pros and cons of the “All In Policy,” where registered programs must attempt to fill all ACGME positions at the program through the Match.15,16 SCAI opted out of the “All In Policy” to allow programs to have flexibility for unique situations that require commitment to a candidate outside of the Match. 

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"As a result of the successful implementation of the Match in IC, the first Match cycle for incoming IC fellows will open in the summer of 2024. Individuals eligible to apply include cardiovascular disease fellows in their third or final year of training and graduates who have completed fellowship and are in clinical practice. This class will start IC training in July 2025"