Jump to comment:

• Yes, Neurointerventional Fellowship Training Should Absolutely be Suspended!
  Kennith F. Layton
  Published on: 13 April 2016
• TOO MANY FELLOWS, TOO FEW JOBS: THE AUSTRALIAN REALITY
  Lee-Anne Slater
  Published on: 13 April 2016
• Are there too many fellowships, or not enough training?
  Dr. Buddy Connors
  Published on: 13 April 2016
• Abolishing Neurointerventional Fellowship Training: A Reality Check
  David A. Rubin
  Published on: 13 April 2016

• Published on: 13 April 2016

  Yes, Neurointerventional Fellowship Training Should Absolutely be Suspended!

  • Kennith F. Layton, Director of Interventional Neuroradiology
  • Other Contributors:
    • Joseph H. Hise, Chief of Radiology

  We would like to add our strong support to the recent editorial by Fiorella, et al. Dr. Fiorella and his colleagues should be congratulated for pointing out the giant elephant in the room. The government, insurers and patients are increasingly demanding more quality, safety and value from the healthcare dollar and, like it or not, we can no longer ignore their pleas. Dr. Fiorella has eloquently shown us with widely ava...

  Show More

  We would like to add our strong support to the recent editorial by Fiorella, et al. Dr. Fiorella and his colleagues should be congratulated for pointing out the giant elephant in the room. The government, insurers and patients are increasingly demanding more quality, safety and value from the healthcare dollar and, like it or not, we can no longer ignore their pleas. Dr. Fiorella has eloquently shown us with widely available data that our profession now has more than enough manpower to handle the labor demands extending into the foreseeable future. The current trend of overproducing neurointerventional fellows has already led to decreased quality and safety and is a profound misallocation of scarce medical resources. These issues are further compounded by the current lack of a standardized training curriculum and certifying examination.

  One other factor that was not mentioned in the editorial is the inevitable replacement of the fee for service payment model with bundled payments or some similar type of payment distribution. It is not a question of if this change will occur, but rather when it will occur. Because the procedures we perform are very expensive, our specialty will be under tremendous scrutiny by the accountable care organizations or other entities that are tasked with managing and allocating the funds for these bundled payments. Simply put, this paradigm shift in healthcare financing will demand that neurointerventionalists intervene only in those situations that are proven effective and provide value. In a world of bundled payments, the focus will absolutely be on conservative medical management rather than complex and expensive interventions. As painful as it may seem to those of us who perform these procedures, it is inevitable. We believe this will contribute to declining neurointerventional volumes in the near future and is why we should halt all neurointerventional fellowship training until there is adequate volume to maintain expertise among current practitioners.

  Unfortunately, we might be too late to stop this runaway train. Given the number of fellows currently being trained and the relatively low rate of retirement from our specialty at this time, we will experience a glut of neurointerventionalists in the next few years. Because there is no consistent scrutiny of quality in the neurointerventional fellowships, there are "puppy mill" fellowships popping up all over the country. These fellowships do not provide adequate procedure complexity, volume or oversight to produce even a marginally competent neurointerventionalist. Sadly, we have seen the recent intrusion of this type of subpar training program into our medical community with as many as six fellows being trained simultaneously in community, suburban, nonacademic hospital facilities. Those of us who practice in the larger, academic, tertiary referral hospitals are now seeing the unfortunate consequences imposed upon the patients. The disasters range from procedures that clearly should have never been attempted, even by experienced operators, to procedures that are declined due to being "technically difficult" despite really being rather straightforward and clinically warranted.

  Obviously, we are just as passionate about this crisis as Dr. Fiorella and his long list of distinguished coauthors. While it might be too late to avert our current crisis, the impact could be dampened if all future fellows that have not yet started their programs and those that are considering our profession were to strongly consider these circumstances and perhaps choose a different subspecialty.

  Thank you for your consideration.

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 13 April 2016

  TOO MANY FELLOWS, TOO FEW JOBS: THE AUSTRALIAN REALITY

  • Lee-Anne Slater, Interventional neuroradiology Fellow
  • Other Contributors:
    • Winston Chong, Michael Holt, Ronil V. Chandra

  Dear Dr. Tarr,

  We read with interest the recent editorial by Fiorella et al., entitled "Should Neurointerventional fellowship training be suspended indefinitely?", detailing the potential hazards of neurointerventional (NI) overtraining in the United States (US).1 We face similar issues in Australia pertaining to our own current NI workforce demand and NI trainee employment outlook.

  The landmass of Aus...

  Show More

  Dear Dr. Tarr,

  We read with interest the recent editorial by Fiorella et al., entitled "Should Neurointerventional fellowship training be suspended indefinitely?", detailing the potential hazards of neurointerventional (NI) overtraining in the United States (US).1 We face similar issues in Australia pertaining to our own current NI workforce demand and NI trainee employment outlook.

  The landmass of Australia is twice the size of the European Union and almost as large as continental US (excluding Alaska and Hawaii).2 However the vast majority (>85%) of the 23 million population live within 30 miles of the coastline, and 98% live in major cities or regional areas where access to NI services are considered to be available.3

  Currently, 30 practising neurointerventionalists service this population. Similar to the USA, most perform additional non-NI work such as diagnostic radiology, medical neurology, or open surgery. Given the core NI skillset of intracranial aneurysm and intra-arterial stroke treatment, we focused our analysis on these specific services.

  Local vendor survey estimates reveal that approximately 1300 aneurysms are treated by endovascular techniques per annum in Australia. This has remained relatively stable over the last 3 years. This yields just over 40 aneurysms per practitioner per year, or almost 1 case every week.

  Approximately 50, 000 people suffered a new or recurrent stroke in 2012 in Australia.4 Approximately 80% were ischemic strokes, and if all patients had presented to comprehensive stroke centers, optimistically 3% could have received intra-arterial therapy. 5 Extrapolating from this data, this could yield a theoretical 1200 cases per year, or under 1 case per practitioner per week. However, the recent simultaneous publication of three randomized clinical trials that failed to demonstrate benefit for intra-arterial therapy in acute ischemic stroke patients will undoubtedly slow this potential growth.6-9 Even if this potential growth came to part fruition, the fact that the current practicing neurointerventionalists in some centers spend up to 50% of their work hours performing non-NI work, means this demand could be easily met by the current pool of practitioners increasing their NI work load.

  Despite this relatively low average case volume per operator, we continue to train additional NI fellows. Currently, 15 Australians are in various stages of NI training either in Australia or overseas. Thus our NI workforce is predicted to expand by up to 50% within four years.

  The oversupply of US NI trainees may be potentially leading to the expansion of NI services at community hospitals, and to the shift of cerebral aneurysm treatment from high-volume to low-volume centers.10 This is a concerning trend for patient safety, as higher volume centers are known to have better outcomes. In Australia, NI services are largely provided by public health services that have significant budgetary constraints. Given the costs associated with an active NI program, there are pressures to contain rather than expand NI services, which are already fully or nearly fully staffed. This situation will persist until there are solid data provided to justify service expansion. For the primary author who is a current NI trainee, this translates into a bleak NI job market. Many NI trainees will likely find that there is no NI position available to them after a protracted and intense course of NI training.

  The low case volume and concerns for quality of patient care also highlight the need to have credentialing for both fellowship programs and existing practitioners to ensure future NI trainees receive an adequate breadth of experience, and existing practitioners maintain safe and quality practice. The Royal Australian and New Zealand Society for Neuroradiology is already in the process of introducing a system of registration and credentialing of NI training programs and defining guidelines for ongoing credentialing of current and future practitioners. This may assist in regulating the imbalance that appears to currently exist.

  We commend Dr. Fiorella and his colleagues for highlighting this important issue. As a global NI community, we have a responsibility to provide prospective NI trainees with a pragmatic view of the current and future NI workforce while protecting the quality of care for our patients. The current Australian reality is that there are too many NI trainees, and too few NI jobs.

  1. Fiorella D, Hirsch JA, Woo HH, Rasmussen PA, Shazam Hussain M, Hui FK, et al. Should neurointerventional fellowship training be suspended indefinitely? Journal of neurointerventional surgery. 2012;4:315-318 2. Australian bureau of statistics: 1301.0 - year book australia, 2009-10. http://www.abs.gov.au/AUSSTATS/abs@.nsf/0/047D4BA4016F7A0BCA25773700169C25?opendocument. Accessed 25 Dec 2013. Last updated 4 Jun 2010. 3. Australian bureau of statistics: 3218.0 - regional population growth, australia, 2012. http://www.abs.gov.au/ausstats/abs@.nsf/Products/3218.0~2012~Main+Features~Main+Features?OpenDocument#PARALINK3. Accessed 25 Dec 2013. Last updated 30 Aug 2013. 4. Stroke foundation.2013 5. Cloft HJ, Rabinstein A, Lanzino G, Kallmes DF. Intra-arterial stroke therapy: An assessment of demand and available work force. AJNR. American journal of neuroradiology. 2009;30:453-458 6. Mocco J, O'Kelly C, Arthur A, Meyers PM, Hirsch JA, Woo HH, et al. Randomized clinical trials: The double edged sword. Journal of neurointerventional surgery. 2013;5:387-390 7. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-pa versus t-pa alone for stroke. The New England journal of medicine. 2013;368:893-903 8. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. The New England journal of medicine. 2013;368:914-923 9. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. The New England journal of medicine. 2013;368:904-913 10. Brinjikji W, Lanzino G, Kallmes DF, Cloft HJ. Cerebral aneurysm treatment is beginning to shift to low volume centers. Journal of neurointerventional surgery. 2013

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 13 April 2016

  Are there too many fellowships, or not enough training?

  • Dr. Buddy Connors, Medical Director II, Interventional Neuroradiology

  As a participant in the creation of the original ACGME ESNR fellowship training standards, I read the article concerning fellowship suspension with great interest (1). The paper is timely and thorough. It is unfortunate that the Neurointerventional world is dealing with so many unknowns. We do not seem to know how many we are, where we work, what we do, or where we were trained. The problem is very well summarized at...

  Show More

  As a participant in the creation of the original ACGME ESNR fellowship training standards, I read the article concerning fellowship suspension with great interest (1). The paper is timely and thorough. It is unfortunate that the Neurointerventional world is dealing with so many unknowns. We do not seem to know how many we are, where we work, what we do, or where we were trained. The problem is very well summarized at the end of the paper. We seem to be spreading our patient population among too many practitioners, which subsequently restricts the number of patients available to each practitioner to stay in practice, make a living, and be proficient.

  The first line states: "The purpose of any training program is to provide a supply of skilled workers to address an unmet demand for their services." The authors discuss numbers of procedures and extrapolate implications but do not discuss what the training was that got these people out into the world. Further, there is no clear statement as to what these unmet needs are. These workers might perhaps be skilled in certain areas, but not know anything about other subjects.

  Adequacy of numbers is the primary thrust of the article. One endovascular neurosurgeon can possibly cover 5 different hospitals by themselves for aneurysms, AVMs etc., and could do 300 aneurysms per year easily. Most, but not all, neurointerventional fellowships provide an adequate number of aneurysms for training. But as correctly pointed out, the numerous auxiliary procedures that are necessary to be proficient in this profession, such as skull base tumor embolization, epistaxis, vertebroplasty, nerve root block or ablation, are not routinely performed at all institutions. AVMs might be completely ignored at many places. Endovascular spinal procedures are rare.

  The gaping hole in fellowship training is acute ischemic stroke. Consistently complete training for all fellows continues to be a void in our profession and a gap in the entire premise of this statement. It is perfectly acceptable to produce specialists in aneurysm intervention as well as vertebroplasty, but we should not count them all in the same bucket and presume we have enough people to cover the nation for stroke. Everyone does not do everything nor do they want to. Many fellowship programs have inadequate caseload and resultant inadequate or poor training in acute stroke treatment. We should not just expect this specialized training to magically appear in fellowships where there is inadequate case volume to begin with. Therefore, what is the true number of interventionists that are available, trained, able, and willing to treat strokes?

  The need for trained physicians to treat stroke is not based upon the number of strokes (as might be the case for aneurysms), but rather on the number of hospitals that need stroke coverage. The issue with stroke coverage is that there needs to be a minimal number of practitioners at each hospital to take call 24/7/365, no matter the number of cases: 1 per month or 1 per day. Another paper describes the necessity of stroke coverage as 2-3 interventionists per center for 24/7/365 coverage (2), contradicting the official SNIS stated position as well as EMTALA (Emergency Medical Treatment and Active Labor Act) that states that no requirement can be made for 24/7 coverage with less than 4 persons. If there is a need for 200 hospitals to have 24/7/365 coverage, then there needs to be at least 800 interventionists just at those hospitals alone.

  The official SNIS position on stroke coverage is as follows: "Current staffing levels at Comprehensive Stroke Centers will rarely allow continuous immediate coverage for IA stroke therapy at all times, 365 days a year. Instantly available coverage on a continuous basis 24/7/365 should not be expected with fewer than 4 persons. Until adequate staffing levels are achieved, continuously available catheter-directed intra- arterial emergency stroke therapy is considered the "ideal", but is not mandatory in order to be classified as Comprehensive Stroke Center. Therefore, in agreement with federal regulations, IA stroke therapy might be available only a portion of the time as determined by local hospital conditions and staffing levels of qualified and appropriately trained personnel, and the institution still qualify as a Comprehensive Stroke Center." (SNIS executive committee, John Barr president, 2005). As we all know, there are very few hospitals that have 4 neurointerventionists.

  There are probably fewer than 20 fellowships in the US that treat by endovascular techniques more than 50 strokes per year. Maybe 10. Even with 50 cases, a "fellow" can only "maybe" attain the SNIS mandated 10 cases as "primary operator" in his last few months. Thus, in the remaining 60-70 fellowships (90%?), the trainees will not get the required experience. There are numerous examples of fellowships that provide a certificate of competency for everything "neurointerventional" where the number of endovascular stroke cases can be counted on one hand... or one finger. How will these fellows get sufficient training, experience, and knowledge to have good outcomes when treating strokes when they are in private practice?

  Foremost, I hope that this call for a moratorium in fellowships will be accompanied by an equally vigorous call for augmented and improved stroke training for fellows and our members. A recent SNIS webinar bemoaned the poor operator performance for intracranial stenting during SAMMPRIS. A recent article has documented "death and destruction" in endovascular stroke therapy (3). The failure of SAMMPRIS and the stoppage of IMS 3 only highlights the fact that we are not doing very well at this. As we all used to believe, IMS 3 should have been a slam-dunk. SNIS/SVIN should offer specialized intensive training courses that are, in actual fact, a responsibility of our professional organizations. Our societies need a plan for improved training and continuing education for our fellows and members in addition to a moratorium.

  References

  1) Fiorella D, Hirsch JA, Woo HH, et al. Should neurointerventional fellowship training be suspended indefinitely? J NeuroIntervent Surg 2012;4:315-318

  2) Zaidat OO, Lazzaro M, McGinley E, et al. Demand-supply of neurointerventionalists for endovascular ischemic stroke therapy. Neurology 2012;79 (Suppl 1):S35-S41.

  3) Cloft HJ. Death and Destruction in the Intra-Arterial Battle with Acute Ischemic Stroke. AJNR Am J Neuroradiol 32:1767-70.

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 13 April 2016

  Abolishing Neurointerventional Fellowship Training: A Reality Check

  • David A. Rubin, Radiologist

  Dear Sir:

  I am not a neurosurgeon, neuroradiologist, nor interventionalist. In fact, I am not a regular reader of your journal. However, the article entitled "Should Neurointerventional Fellowship Training Be Suspended Indefinitely?" by David Fiorella, et al., was brought to my attention, unsolicited, by several different medical web sites. I have no objection to the logic and opinions expressed, and actually h...

  Show More

  Dear Sir:

  I am not a neurosurgeon, neuroradiologist, nor interventionalist. In fact, I am not a regular reader of your journal. However, the article entitled "Should Neurointerventional Fellowship Training Be Suspended Indefinitely?" by David Fiorella, et al., was brought to my attention, unsolicited, by several different medical web sites. I have no objection to the logic and opinions expressed, and actually have no opinion on the issue for or against these fellowships. But I feel I must register my shock at what I see as a glaring omission by the journal.

  The many authors do indicate their respective affiliations, and cumulatively list in their disclosure, "Competing interests: None." The most important disclosure, however, is not listed anywhere as a conflict of interest. Namely, how many of the authors are practicing, already fellowship-trained neurointerventionalists? In order to get a sense of any potential bias, I think the reader would want to know this fact about each author. Certainly, if most (or all) of the authors currently practice as neurointerventionalists, regardless of their arguments, some readers might feel that their position and recommendations simply represent an effort to restrict competition for their own advantage, and that the journal has given them a platform to advance this protectionist goal. If General Motors found themselves with a surplus of unsold cars and made the argument that there were too many autos already on the road, I might agree with that statement. But if their proposed solution was to ban further manufacture of cars so that they would have less competition unloading their inventories, I might object. Perhaps another company could produce cars that would be better (more efficient, safer, faster, etc.) and preventing them from doing so would hurt consumers, who would have fewer options. Similarly, while the authors may have correctly described the current problem (too many neurointerventionalists with not enough cases) their proposed solution (blocking further entries into the field) could be seen as self-serving. After all, maybe there are potential trainees or training programs who would introduce better practitioners (more efficient, safer, faster, etc.) into the market place, pressuring current (and future) neurointerventionalists to continue to improve the services they now deliver.

  I invite each of the authors of the original article (and of any subsequent supportive letters) to make that disclosure: who among you are neurointerventionalists who have already enjoyed the benefits of fellowship training? Like any disclosure, this should not lessen your stated arguments; rather it will just allow the reader to know whence your recommendations are coming from. It only seems fair to be transparent. I'm just saying.

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top