President's Message, February 2013
Dileep Yavagal, M.D.
Dear SVIN Members,
Greetings and Best wishes for a fantastic 2013 to all of you!
A recent debate has started in our field regarding need for curbing or even stopping the training of fellows. The reasons for the debate are somewhat obvious and mainly based on the fear of potential oversupply of practitioners. Such an oversupply could lead to low patient and procedure volumes for currently practicing Neurointerventionalists - most of us could become “the low-volume operator”. This has been a recurrent fear in interventional cardiology (Fye_circulation_2004; 109:813). Interestingly, this fear has never materialized.
Moratorium of fellowship training is highly unprecedented in any currently practiced medical subspecialty in the US. My personal contention is that while such a debate is healthy, a moratorium on fellowship training is highly pre-mature. Fellowship training of physicians is the bedrock of subspecialty healthcare delivery including Neuroendovascular care in the US and all around the world. It is also the engine for continued growth of a new sub-specialty. A continuous supply of fellowship-trained subspecialists allows for activities beyond performance of the routine clinical care, including: clinical and translational research to grow the specialty, organization of the specialty such as medical societies and examination boards, and supply of consultative expertise to the biomedical industry. In the US, the number of fellowship positions in ACGME accredited subspecialties are based on ACGME approval using patient volume at a given fellowship program and number of faculty as the essential criteria. This strategy seems to have worked fine for all these years and has avoided oversupply of practitioners in fields that widely adopt ACGME accreditation. One the reasons could be that the ratio of patients to practitioners is dynamic over time. Patient volumes can increase over time based on increased access to subspecialists (increased number of comprehensive stroke centers for IACT) and increased awareness about the availability and early evidence of efficacy of therapies. This was seen with PCI for MI in cardiology with a 260% increase in volume between 1987 and 2000 (Fye_2004). Also, it is common to see the applications for fellowship positions go down if available jobs in the subspecialty are oversubscribed, leading to fellowship programs being closed down. However, a unilateral moratorium on training by current practitioners of a subspecialty has very little precedent. It runs the risk of being viewed as self-serving and survivalist move by the practitioners at the cost of benefit to the subspecialty, the future trainees and the patients that it serves.
Neurosurgery’s Approach to Neurointerventional Training
There is another very problematic concurrent development occurring along with the call for fellowship moratorium; some of the very thought leaders advocating for stopping fellowship training in the Neurointerventional field are implementing in-folded training of Neurosurgery residents in Neurointervention. These contradictory steps can only be viewed as a disingenuous effort by Neurosurgery to ensure that only Neurosurgery residents get trained in the subspecialty in the future with no training opportunities for residents in Neurology and Radiology. SVIN, in accordance with its mission, is obligated to its membership to mount all its resources to oppose such political and turf-protecting efforts by sister specialties in our field.
To those who propose moratorium on training, here are my counterproposals:
1. Embrace ACGME accreditation widely,
2. Establish ABMS board certification
3. Consider increasing the fellowship training to three years to include a mandatory year of research in Neurointervention.
Embrace ACGME accreditation:
Fellowship training in Neurointervention, regardless of subspecialty can draw from the experience of supply and demand in Cardiology. In the 1990’s there was a consensus that too many interventional cardiologists were being trained (Ullyot D. Work force issues in cardiology. J Am Coll Cardiol. 1995;25:278–279). However, once ACGME accreditation and board certification of interventional cardiology trainees took hold, the number of accredited training positions was limited and actually led to a shortage of supply of interventional cardiologists (Fye_2004). Our field can similarly avoid an “all or none” approach and use ACGME accreditation to have a finite number of high-level accredited training positions. The problem is not that there are too many training positions in Neurointervention in the US, but that we have not embraced ACGME accreditation.
Establish ABMS board certification in Neurointervention:
The reason programs have not widely embraced ACGME certification is that there is no incentive to do so in the absence of board certification. Therein is the need for the additional step of creating board certification for Neurointervention to complete the systematic organization of standard training. SVIN is working closely with the representatives from SNIS and Neurosurgery to overcome the political hurdles in applying for American Board of Medical Subspecialties (ABMS) certification. I am pleased to share with you that this representative group seems to have made significant progress over the last few months towards this goal after years of discussion with little action. We have reason to be optimistic that board certification in our field could be a reality in the near future.
Add a Third Year of Research in fellowship training for board eligibility:
While this is initially a hard proposal to stomach, a third year of fellowship training focused on research would have the dual effect of solid training in scientific investigation for fellows as well as creation of a dedicated workforce for impactful research. As a collateral effect, it would also slow the rate of graduating fellows. Above all, we will have committed serious time and resources to increasing new knowledge in our field via research. Given the maturing of our field this would not be unusual as is seen in Ob-Gyn subspecialty fellowships and certainly closer to the four year interventional cardiology fellowships. This would also force “in-folded” training programs to add a higher bar for those who want to pursue the subspecialty of Neurointervention and not allow them to complete the training to be board eligible in the same duration as their residency.
In summary, while the perception that “too many fellows are being trained” currently in Neurointervention may not be misplaced, intermediate solutions to balance the needs of our specialty would be more sanguine rather than the drastic step of a moratorium on training fellows. SVIN is committed to participating in this debate actively and protecting the growth of the subspecialty and interests of current and future and interventional Neurologists.
I invite you to send your thoughts on this critical issue to the SVIN listserve (under the “members only” section of the SVIN website at:
A healthy discussion among the SVIN membership will be crucial to informing SVINs actions on this issue.
Dileep R. Yavagal, MD