Downloaded from http://jnis.bmj.com/ on November 14, 2015 - Published by group.bmj.com
PostScript
LETTERS TO THE EDITOR
Too many fellows, too few jobs: the Australian reality We read with interest the recent editorial by Fiorella et al,1 entitled ‘Should neurointerventional fellowship training be suspended indefinitely?’, detailing the potential hazards of neurointerventional (NI) overtraining in the USA. 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 USA (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 practicing 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 past 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 About 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 these 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
J NeuroIntervent Surg Month 2014 Vol 0 No 0
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 4 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 et al 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.
Lee-Anne Slater, Winston Chong, Michael Holt, Ronil V Chandra Interventional Neuroradiology, Department of Diagnostic Imaging, Monash Health, Melbourne, Australia Correspondence to Dr L Slater, Interventional Neuroradiology, Department of Diagnostic Imaging, Monash Health, Melbourne, Australia; [email protected] Competing interests None. Provenance and peer review Not commissioned; not externally peer reviewed. To cite Slater L-A, Chong W, Holt M, et al. J NeuroIntervent Surg Published Online First: [ please include Day Month Year] doi:10.1136/neurintsurg2014-011189 Accepted 25 February 2014
▸ http://dx.doi.org/10.1136/neurintsurg-2012-010471 J NeuroIntervent Surg 2014;0:1. doi:10.1136/neurintsurg-2014-011189
REFERENCES 1
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7
8
9
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Fiorella D, Hirsch JA, Woo HH, et al. Should neurointerventional fellowship training be suspended indefinitely? J Neurointerv Surg 2012;4:315–8. Australian bureau of statistics: 1301.0—year book Australia, 2009–10. http://www.abs.gov.au/AUSSTATS/ [email protected]/0/047D4BA4016F7A0BCA25773700169C25? opendocument (accessed 25 Dec 2013). Last updated 4 Jun 2010. Australian bureau of statistics: 3218.0—regional population growth, Australia, 2012. http://www.abs.gov. au/ausstats/[email protected]/Products/3218.0~2012~Main +Features~Main+Features?OpenDocument#PARALINK3 (accessed 25 Dec 2013). Last updated 30 Aug 2013. National Stroke Foundation - Australia. https:// strokefoundation.com.au/health-professionals/toolsand-resources/facts-and-figures-about-stroke/ (accessed 25 Dec 2013). Cloft HJ, Rabinstein A, Lanzino G, et al. Intra-arterial stroke therapy: an assessment of demand and available work force. AJNR Am J Neuroradiol 2009;30:453–8. Mocco J, O’Kelly C, Arthur A, et al. Randomized clinical trials: the double edged sword. J Neurointerv Surg 2013;5:387–90. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368:893–903. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368:914–23. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013;368:904–13. Brinjikji W, Lanzino G, Kallmes DF, et al. Cerebral aneurysm treatment is beginning to shift to low volume centers. J Neurointerv Surg Published Online First: 8 Jun 2013. doi:10.1136/neurintsurg-2013-010811
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Downloaded from http://jnis.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Too many fellows, too few jobs: the Australian reality Lee-Anne Slater, Winston Chong, Michael Holt and Ronil V Chandra J NeuroIntervent Surg published online March 14, 2014
Updated information and services can be found at: http://jnis.bmj.com/content/early/2014/03/14/neurintsurg-2014-01118 9
These include:
References Email alerting service
This article cites 6 articles, 3 of which you can access for free at: http://jnis.bmj.com/content/early/2014/03/14/neurintsurg-2014-01118 9#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript
LETTERS TO THE EDITOR
Too many fellows, too few jobs: the Australian reality We read with interest the recent editorial by Fiorella et al,1 entitled ‘Should neurointerventional fellowship training be suspended indefinitely?’, detailing the potential hazards of neurointerventional (NI) overtraining in the USA. 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 USA (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 practicing 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 past 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 About 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 these 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
J NeuroIntervent Surg Month 2014 Vol 0 No 0
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 4 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 et al 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.
Lee-Anne Slater, Winston Chong, Michael Holt, Ronil V Chandra Interventional Neuroradiology, Department of Diagnostic Imaging, Monash Health, Melbourne, Australia Correspondence to Dr L Slater, Interventional Neuroradiology, Department of Diagnostic Imaging, Monash Health, Melbourne, Australia; [email protected] Competing interests None. Provenance and peer review Not commissioned; not externally peer reviewed. To cite Slater L-A, Chong W, Holt M, et al. J NeuroIntervent Surg Published Online First: [ please include Day Month Year] doi:10.1136/neurintsurg2014-011189 Accepted 25 February 2014
▸ http://dx.doi.org/10.1136/neurintsurg-2012-010471 J NeuroIntervent Surg 2014;0:1. doi:10.1136/neurintsurg-2014-011189
REFERENCES 1
2
3
4
5
6
7
8
9
10
Fiorella D, Hirsch JA, Woo HH, et al. Should neurointerventional fellowship training be suspended indefinitely? J Neurointerv Surg 2012;4:315–8. Australian bureau of statistics: 1301.0—year book Australia, 2009–10. http://www.abs.gov.au/AUSSTATS/ [email protected]/0/047D4BA4016F7A0BCA25773700169C25? opendocument (accessed 25 Dec 2013). Last updated 4 Jun 2010. Australian bureau of statistics: 3218.0—regional population growth, Australia, 2012. http://www.abs.gov. au/ausstats/[email protected]/Products/3218.0~2012~Main +Features~Main+Features?OpenDocument#PARALINK3 (accessed 25 Dec 2013). Last updated 30 Aug 2013. National Stroke Foundation - Australia. https:// strokefoundation.com.au/health-professionals/toolsand-resources/facts-and-figures-about-stroke/ (accessed 25 Dec 2013). Cloft HJ, Rabinstein A, Lanzino G, et al. Intra-arterial stroke therapy: an assessment of demand and available work force. AJNR Am J Neuroradiol 2009;30:453–8. Mocco J, O’Kelly C, Arthur A, et al. Randomized clinical trials: the double edged sword. J Neurointerv Surg 2013;5:387–90. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368:893–903. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368:914–23. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013;368:904–13. Brinjikji W, Lanzino G, Kallmes DF, et al. Cerebral aneurysm treatment is beginning to shift to low volume centers. J Neurointerv Surg Published Online First: 8 Jun 2013. doi:10.1136/neurintsurg-2013-010811
1
Downloaded from http://jnis.bmj.com/ on November 14, 2015 - Published by group.bmj.com
Too many fellows, too few jobs: the Australian reality Lee-Anne Slater, Winston Chong, Michael Holt and Ronil V Chandra J NeuroIntervent Surg published online March 14, 2014
Updated information and services can be found at: http://jnis.bmj.com/content/early/2014/03/14/neurintsurg-2014-01118 9
These include:
References Email alerting service
This article cites 6 articles, 3 of which you can access for free at: http://jnis.bmj.com/content/early/2014/03/14/neurintsurg-2014-01118 9#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
