Author + information
- Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions∗ ()
- ↵∗Address correspondence to:
Dr. Spencer B. King III, Saint Joseph’s Heart and Vascular Institute, 5665 Peachtree Dunwoody Road NE, Atlanta, Georgia 30342.
On the morning of July 1, I sat listening to my younger colleagues orient the new interventional fellows to the mysteries of the Emory interventional cardiology fellowship and their responsibilities. I thought to myself, “How quickly will these new fellows assimilate the knowledge and wisdom required for their level of training?” Will it happen on day one? There is an old adage that as a patient, you want to avoid any elective admission to a hospital during the first week of July; although I cannot document any actual disasters throughout my career, I do remember the anxiety relating to the incoming crop of new trainees. Whereas I spent a most relaxed Fourth of July with my family at our lake cabin, I remember many years past that I could not afford to be relaxed because of concern for the level of medical care during that first week of fellowship. I learned at the orientation that the majority of these new fellows were from the Emory cardiology program, and therefore, much of the learning curve about policies and procedures had already been mastered. They did dutifully introduce themselves and related their specific interests. Most of them indicated they were interested in general interventional cardiology (whatever that means these days). One fellow, however, was the designated structural heart disease fellow who undoubtedly will receive extensive training from a very busy structural heart program.
I began to wonder about the future for training programs in interventional cardiology. Seventeen years ago when we were planning the application to the American Board Medical Specialties (ABMS) for an interventional cardiology fellowship and boards, the expectations were quite different from what they are today. The challenges for a competent interventional cardiologist in the 1990s was extensive experience in all the vagaries of coronary interventions. The new devices, be they successful or not, were all being tried, and stenting was in its infancy. Complications were common, and much of the training revolved around how to avoid them and how to escape once they occurred. Peripheral vascular interventions were being performed by some interventional cardiologists, but because of massive resistance from radiology, peripheral vascular interventions were not included in the initial training requirement. Today the expectation from interventional cardiology practices may be quite different. Coronary interventions have become much more standardized, and the remaining challenge, chronic total occlusions, has become the purview of operators with special experience in the techniques to address that problem. But as interventional cardiology embraces peripheral vascular interventions and, much more vigorously, structural heart disease problems, the appropriate training for interventional cardiologists is a question that is as yet incompletely addressed. If one accepts the premise that peripheral vascular interventions require adequate training and experience, especially carotid artery interventions, and that the same applies for structural heart disease interventions, how will this training be provided and to whom? The Core Cardiovascular Training Statement (COCATS) document for training in cardiology now reflects a list of competencies that are to be mastered during the 3-year training program. Training documents addressing interventional cardiology training will be challenged to identify the competencies related to this dramatically changed subspecialty. Many programs have already migrated toward specialized tracks, such as the structural heart disease track at Emory and peripheral vascular disease tracks. Do these specialized programs require specialized competencies not necessary for interventional cardiologists concentrating principally on coronary interventions? The answer seems obvious, but as yet there is no uniform requirement for such training.
Seventeen years ago, the training being delivered heavily influenced the recommendations that were made to the ABMS and the Residency Review Committees. Once those requirements were published, training programs became more standardized as they complied with those requirements. The question now is whether the training programs in peripheral vascular and structural heart disease developing around the country should influence the establishment of special certification in those procedures and be designated by the ABMS. The changing face of interventional cardiology also requires consideration by the American College of Cardiology, the Society for Cardiac Angiography and Intervention, and perhaps others toward the appropriate workforce needed to address the changing health burden and technological evolution that has placed new demands on the delivery of interventional cardiology care. If interventional cardiologists are to gain expertise in all aspects of interventional cardiology, the added year of training would at least solve one problem for program directors. Overlapping fellow trainees would ensure that experienced house staff remained at the end of the year, and the fear of the first of July might be lessened. Program directors of the future should be able to relax on the Fourth of July.
- American College of Cardiology Foundation