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Are there too many fellowships or not enough training?
  1. Buddy Connors
  1. Correspondence to Dr Buddy Connors, Department of Radiology, Vanderbilt University Medical Center, 1161 21st Ave. South, Nashville, TN 37232, USA; budmancon{at}gmail.com, buddy.connors{at}vanderbilt.edu

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As a participant in the creation of the original Accreditation Council for Graduate Medical Education fellowship training standards for Endovascular Surgical NeuroRadiology, 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 do not know anything about other subjects.

Adequacy of numbers is the primary thrust of the article. One endovascular neurosurgeon can possibly cover five different hospitals for aneurysms and arteriovenous malformations (AVMs), and could easily do 300 aneurysms per year. 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 and 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 an inadequate case load 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 an inadequate case volume to begin with. What, therefore, 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—one per month or one 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 Society of NeuroInterventional Surgery (SNIS) stated position as well as the Emergency Medical Treatment and Active Labor Act which state that no requirement can be made for 24/7 coverage with fewer than four 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 intra-arterial stroke therapy at all times, 365 days a year. Instantly available coverage on a continuous basis 24/7/365 should not be expected with less than four 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, intra-arterial 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.’ (John Barr, President, SNIS Executive Committee, 2005).

As we all know, there are very few hospitals that have four neurointerventionists.

There are probably fewer than 20 fellowships in the USA that treat more than 50 strokes per year by endovascular techniques—maybe 10. Even with 50 cases, a ‘fellow’ can only ‘maybe’ attain the SNIS-mandated 10 cases as a ‘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 the SAMMPRIS trial. A recent article has documented ‘death and destruction’ in endovascular stroke therapy.3 The failure of the SAMMPRIS trial and the stoppage of the IMS 3 trial only highlights the fact that we are not doing very well at this. As we all used to believe, the IMS 3 trial should have been a sure thing. The SNIS and the Society of Vascular and Interventional Neurology (SVIN) should offer specialized intensive training courses that are, in 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

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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