The Advanced Heart Failure and Transplant Cardiology Application Process: Lessons Learned

Contributed by Guest Authors Donya Mohebali, MD, and Michelle M. Kittleson, MD, PhD

In 2019, the Heart Failure Society of America (HFSA) sponsored participation in the National Resident Matching Program Medical Specialties Matching Program for Advanced Heart Failure and Transplant Cardiology (AHFTC) Fellowship starting for the 2020 academic year. This decision was reached after considerable discussion among ACGME-accredited AFHTC program directors. With a uniform timeline and application process, the Match now allows fellows and programs alike to evaluate each other without undue pressure and influence to make binding decisions on varying and arbitrary timelines.

For the 2020-2021 academic year, 63 AHFTC fellowship programs participated in the Match with available positions. Of the 82 fellows who participated, 80 matched to AHFTC fellowships. These metrics indicate that the AHFTC Match, in its inaugural year, was successful. Here, as future AHFTC fellow and AHFTC program director, we offer lessons learned to optimize the process for future fellows.

Lesson 1: Reflect on your past as well as your future

As you consider your experiences in medical training, identify what learning environments and learning styles were most effective for you.Important questions to consider:

Do I learn best by experiencing a high volume of cases versus having a slower pace to absorb and deliberate?
Do I prefer working through patient management plans with more autonomy or do I prefer more supervision?
Do I learn best by being in the trenches of patient care (writing orders, calling consults, writing notes), taking on a supervisory role, or a combination of both?
As important as your past experiences are your future goals. Finally, the light is at the end of the training tunnel and it is time to figure out where you career will take you. While none of these decisions are ever binding, it’s useful to think through your priorities. Consider the following:
Do I want your future career to be primarily research-oriented, clinical, or a combination?
Do I see myself at a heart transplant versus destination therapy ventricular assist device center?
Is it important for me to work in an academic medical center?
Do I ultimately want leadership roles in an AHFTC program and/or national/international AHFTC organizations?

Lesson 2: Be Prepared

As AHFTC fellowship is the final frontier of training, be ready for questions about your specific career plans. Organizing your priorities as above will prepare you for the interview trail and will allow you to critically evaluate programs vis a vis your specific career goals.

Remember, anything listed on your CV is fair game for questions. Other questions you can expect (and will remember from prior interview cycles):

Why AHFTC?
Where do you see yourself in 5-10 years?
What will be your clinical or research niche?
Tell me about an interesting clinical case.
Tell me about your involvement in research project X.
Why are you interested in our program?

Ask for a list of interviewers in advance and read up on their interests; you will likely interview with most or all of the AHFTC staff physicians on interview day. If there are individuals with similar research or clinical interests not on your roster, request a meeting with them on interview day if possible.

For the programs you are very interested in, after interview day, reach out to recent graduates to get their perspective on their training. In addition, let your cardiology fellowship program director/mentor know which programs you regard highly; a personal call from them to your top choice(s) can only bolster your prospects.

However, two caveats: first, be selective; the AHFTC community is small and if you or your mentor relay your strong interest to more than a few programs, programs may question your true level of interest. Second, do not feel pressured to declare your love for any program until you are sure. Take the time afforded to you by the Match process to critically evaluate the programs in light of your educational and career priorities.

Another benefit of preparation: you shine not only as an AHFTC fellow applicant, but as a potential faculty member. Interviews for AHFTC fellowship allow you to network in the tight-knit AHFTC faculty community and make connections that may aid your future job search, no matter where you complete your fellowship.

Lesson 3: Learn about the culture—not just the facts—of a program

After countless interviews, the details of individual programs will blend together. Which program has a combined transplant/heart failure/ mechanical circulatory support (MCS) service, and which has three separate services? Which program had fellows write all notes and which program had fellows write none? While details matter, how many consults you call or notes you write is unlikely to be the deal-breaker for any program. Rather, critically evaluate programs using three important tenets of medical education noted above: volume, autonomy, and mentorship.

Volume: learning happens through experience, and one means of gaining experience is volume. For some, more volume will be an advantage while for others, a slower pace is preferable. Specific questions to ask to evaluate volume:

What is the annual volume of transplant and durable mechanical circulatory support (MCS) devices?
What is the average census and breakdown (transplant, MCS, heart failure) of the inpatient services?
What is the average census in the outpatient clinics?
How many endomyocardial biopsies and other procedures do fellows generally perform over the fellowship?

Autonomy: Some learn best by working through patient management plans with more autonomy, and others prefer more supervision. Specific questions to ask (and the current fellows are likely the best source of accurate information):

How does the call structure work? Do fellows receive the first call from nurses, patients, residents, outside hospitals?
If a fellow is first call, what is the attending support structure for the on-call fellow?
How are fellows involved in donor call?
How do you find the balance of independence and supervision on inpatient rounds, outpatient clinics, and in the cardiac catheterization laboratory?

Mentorship: Ultimately, all of medicine is an apprenticeship and we learn by modeling ourselves after people we admire. The AHFTC community is a rich source of mentorship, and the key is to determine if there are role models for you among the AHFTC faculty at a given institution and if so, they are amenable to mentoring. Again, fellows are often the best source of this information, including former AHFTC fellowship graduates who can better reflect on how the training has impacted their practice.

Are there opportunities to engage in research?
Do you find adequate support for research at the level you require it, from formulating a research question, collecting and analyzing data, drafting the manuscript, to manuscript submission?
What is the track record of prior fellows in their research output during the AHFTC fellowship year?
Do you find the AHFTC faculty open to mentorship regarding topics ranging from patient management to work-life balance?
How has the program assisted you with your search for a faculty position?
Where have former graduates of the program secured jobs?

What can AHFTC programs do to help fellows?

There are ways to make the AHFTC application process more useful for applicants. First, to aid applicants in the complex process of planning multiple interviews, it is ideal to have a set timeline noted on the program website indicating when applicants can expect to be notified about interviews and when interviews will occur. Ideally, applicants should have at least a month between the invitation for an interview and the actual interview dates so there is time to obtain coverage and secure travel plans.

Second, have a set schedule on interview day. This can be challenging in the context of a busy program, but invaluable for applicants. One general model includes: 1) morning rounds; 2) lunch and tour with the current fellows; 3) afternoon interviews that include meetings with the AHFTC program director and heart failure/transplant physician leadership.

Third, as is obvious, respect the Match. It is a great relief, as a program director, to know that every other program is operating under a uniform timeline and there is no pressure to interview ever earlier out of fear of missing out on available candidates. Let applicants know if you regard them highly, but do not put pressure on them to reciprocate.

Conclusion

The ability of AHFTC applicants to use the Match takes the pressure of an unpredictable and varying timeline out of the equation, and applicants can now reflect on their learning process, future goals, and critically evaluate how different AHFTC programs would allow them to achieve those goals. AHFTC programs in turn can engage in an unhurried interview processes to carefully review applicants. In the end, this evaluation, by allowing programs and fellows to find the mutually best fit, will benefit the AHFTC community for years to come.

Author Information

Donya Mohebali, MD ([email protected])
Beth Israel Deaconess Medical Center, Cardiovascular Division, Boston, Massachusetts

Michelle M. Kittleson, MD, PhD ([email protected])
Division of Cardiology. Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California

Address correspondence to:
Donya Mohebali, MD
Beth Israel Deaconess Medical Center, Cardiovascular Division, 330 Brookline Avenue Boston MA 02115
Phone: 617-667-8800, Fax 617-632-7760
Email: [email protected]