International Journal of Cardiology 198 (2015) 134–135
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Multidisciplinary training in cardiovascular fellowship programs Mohamad Alkhouli a,⁎, Craig R. Narins a,b, Frederick S. Ling a a b
Division of Cardiovascular Diseases, University of Rochester, Rochester, NY, United States Vascular Surgery Division, University of Rochester, Rochester, NY, United States
a r t i c l e
i n f o
Article history: Received 29 June 2015 Accepted 30 June 2015 Available online 5 July 2015 Keywords: Multidisciplinary Training Cardiovascular disease fellowship
The management of complex cardiovascular disease is rapidly shifting from individual physician based practice towards a multidisciplinary team approach. The plethora of scientific data and the development of new strategies of care led to the wide adoption of the ‘Heart Team’ or the ‘Cardiovascular Team’ concept, where cardiologists work closely with cardiac surgeons, vascular surgeons, neurologists, anesthesiologists, radiologists, interventional radiologists and other specialists to deliver a high-quality cardiovascular care. The importance of this ‘patient-centered’ and not ‘specialty-centered’ approach is well recognized by multiple societies and its adoption is therefore strongly recommended in most contemporary guidelines [1]. The evolution of this collaborative team approach has transformed how cardiovascular specialists interact and provide patient care, and possibly resulted in improved outcomes. Unfortunately, educational models have not kept pace with these changes. In most cardiovascular fellowship training programs, fellows' exposure to other key specialties is limited to didactic lectures, and scattered patient-care related interactions. In the era of multispecialty team approach, this exposure of cardiovascular fellows to their future team collaborators is far from adequate. The most recent guidelines for Training in Adult Cardiovascular Medicine acknowledge the importance of multidisciplinary training but do not provide specific recommendations with regard to its application [2]. The guidelines states that ‘specialists in cardiovascular disease must interact with generalists and specialists in other areas and have knowledge of other specialties to provide excellent patient care. Close
⁎ Corresponding author at: Division of Cardiovascular Diseases, University of Rochester, Rochester, NY, 601 Elmwood Avenue, Box 679C, Rochester, NY 14642-8679, United States. E-mail address: [email protected] (M. Alkhouli).
http://dx.doi.org/10.1016/j.ijcard.2015.06.179 0167-5273/
interaction with cardiovascular/cardiothoracic surgery is of particular importance’. It also states that ‘attendance at multidisciplinary conferences is highly desirable, particularly at conferences closely related to cardiovascular disease, such as conferences on surgery, radiology, and pathology’. Not infrequently, cardiovascular fellows are advised by their mentors to spend time in the operating room, at the vascular clinic and in the cardiothoracic intensive care unit. However, in most ACGMEaccredited cardiology training programs, there are no structured rotations in any of the key cardiology-related disciplines. The planning and undertaking of such rotations are left to the initiative of the fellows, but is rarely achieved due to time constrains, administrative hurdles, political barriers, the need to spend elective time in their future subspecialty, and the absence of goals and objectives for such rotations. These potential issues often lead the fellows away from what can potentially be not only an excellent educational experience but also a great opportunity to foster and enhance a multidisciplinary mentality among trainees. In this letter, we suggest the integration of structured welldesigned rotations in some of the key related disciplines in the curriculum of cardiovascular fellowship training programs.
1. Cardiac imaging Radiologists and cardiologists have different skill sets, and working alongside each other allows a synergistic development of knowledge and expertise. Radiologists are more familiar with cross-sectional imaging, radiation concepts and contrast dynamics, whereas cardiologists bring expertise in clinical pathways, cardiac pathophysiology, and management implications of results. Traditionally, nuclear cardiology imaging has been managed by either radiologists or cardiologists with little interplay. The evolution of cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging and the expansion of their applications, have changed this theme and partially abolished the isolation between the two specialties. The recently published COCATES 4 guidelines (Task Force 4) proposed that training in all components of cardiac imaging modalities (echocardiography, nuclear imaging, CCT and CMR) become integrated in a novel training model; multimodality imaging. These recommendations stem from the increasing awareness of the need for deeper integration of cardiac imaging modalities to facilitate patient-centered imaging, and to provide optimal, safe and costeffective care. However, a practical application of these recommendations would not be possible without serious and strategic collaboration with our radiology colleagues. Also, achieving competency in multimodality imaging may not be feasible with dedicated blocks of time, but rather
M. Alkhouli et al. / International Journal of Cardiology 198 (2015) 134–135
requires a more gradual training methodology. Therefore, creative longitudinal training models will be needed. The initiative to develop these models can be undertaken by motivated cardiology and radiology fellows, but requires continuous support by training directors in both disciplines. 2. Vascular care The increasing awareness of peripheral vascular disease, our improved understanding of its pathophysiology, and the advances in endovascular therapeutics and medical therapy have resulted in the evolution of vascular disease management in the last two decades. Due to the high morbidity and mortality of cardiac disease in patients with peripheral vascular disease, cardiologists now frequently provide primary vascular and cardiac care for these patients. This paradigm change is reflected by the increasing number of peripheral endovascular interventions performed by cardiologists (42% of all peripheral interventions in 2011) [3]. Although cardiologists may have good understanding of atherothrombosis and medical therapy and excellent catheter skills, they do not possess the deep knowledge of peripheral vascular disease that vascular surgeons, who traditionally provided vascular care for these patients, possess. Centers of excellence are now transforming from heart centers to heart & vascular centers, where vascular specialists from multiple disciplines complement each other's skills to provide optimal vascular care. The COCATES 4 (Task Force 9) document recommends that all cardiovascular fellows achieve level I training in vascular medicine. This basic level of training requires the trainees to participate in the evaluation and the management of patients with arterial, venous, and lymphatic disorders in the inpatient and outpatient settings. It also states that fellows should be familiar with the interpretation of vascular imaging reports, and become comfortable in the measurement of ankle–brachial index using hand-held Doppler devices. Often, these requirements cannot be fulfilled without spending dedicated time with non-cardiology vascular specialists. At our center, the vascular surgery rotation is an essential part of the cardiovascular fellowship curriculum. The goals of this rotation are to learn basic concepts behind vascular surgery, clinical decision making in vascular surgical patients, basic nonoperative care, ultrasonography in the noninvasive lab, pre-operative decision making and treatment options for peripheral vascular disease. Fellows with interest in endovascular interventions and interventional cardiology fellows additionally spend one month on the vascular surgery service, during which they perform endovascular interventions in the hybrid operating room and provide pre- and post-operative care for vascular patients. Vascular surgery fellows are offered an optional cardiovascular rotation split between the cardiac intensive care unit and the catheterization laboratory. A joint conference for cardiovascular and vascular surgery fellows is held every month, during which both fellows present interesting cases with background literature. 3. Cardiac surgery The emphasis on the collaboration between cardiologists and cardiac surgeons in a ‘Heart Team’ began after the results of the landmark SYNTAX (SYNergy Between PCI [percutaneous coronary intervention]
135
With TAXUS and Cardiac Surgery) trial were published [1]. This trial underscored the importance of a team approach to provide patients with complex or multivessel coronary disease with the best and most appropriate treatment. The ‘Heart Team’ concept later gained a wide spread attention after the introduction of transcatheter aortic valve replacement (TAVR). The introduction of TAVR offered cardiovascular trainees involved in the procedure with the opportunity to closely interact with cardiac surgeons and cardiac surgery fellows at the weekly TAVR meetings, during the procedure and in the post-operative setting. Although cardiology and cardiac surgery are intimately related fields, fellows in these two disciplines historically rarely interacted with each other and often graduated with inconsistent knowledge of each other's specialty. In the pre-TAVR era the major forum of interaction between cardiovascular fellows and their cardiac surgery peers at our institution was during the joint monthly clinical cardiology/cardiac surgery conference. However, the inception of the TAVR program strengthened the relationship between fellows across the two specialties, improved their understanding of each other's discipline, and promoted knowledge exchange and collaborative research initiatives. Cardiac surgery fellows have since asked to rotate through the catheterization laboratory and experience first-hand the planning and the performance of diagnostic catheterization and percutaneous interventions. Cardiovascular fellows attended surgical journal club activities that were previously limited to surgeons and surgery fellows. Training directors can build upon the positive multidisciplinary environment brought by the introduction of the ‘Heart Team’ concept to design an educational model that will provide both cardiovascular and cardiac surgery fellows with the knowledge and experience needed to transition seamlessly into effective ‘Heart Team’ members upon graduation. The ‘Heart Team’ concept has been gaining increasing momentum over the past decade. Tremendous efforts have been made by administrators and staff members across the country to overcome the challenges and effectively implement this concept at their workplace. However, little attention has been made with regard to early integration of this concept during fellowship training. Introducing solid multidisciplinary training models into cardiovascular fellowship training programs will provide the cardiovascular trainee with invaluable experience, continue to break the historical barriers across specialties, and pave the way to a better multidisciplinary patient-centered cardiovascular care. Conflict of interest None. References [1] D.R. Holmes, J.B. Rich, W.A. Zoghbi, M.J. Mack, The heart team of cardiovascular care, J. Am. Coll. Cardiol. 61 (9) (2013) 903–907. [2] E.S. Williams, J.L. Halperin, V. Fuster, ACC 2015 Core Cardiovascular Training Statement (COCATS 4) (Revision of COCATS 3)Epub ahead of print 2015. http://dx.doi.org/10. 1016/j.jacc.2015.03.017. [3] W.S. Jones, X. Mi, L.G. Qualls, S. Vemulapalli, E.D. Peterson, M.R. Patel, L.H. Curtis, Trends in settings for peripheral vascular intervention and the effect of changes in the outpatient prospective payment system, J. Am. Coll. Cardiol. 65 (9) (2015) 920–927.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Multidisciplinary training in cardiovascular fellowship programs Mohamad Alkhouli a,⁎, Craig R. Narins a,b, Frederick S. Ling a a b
Division of Cardiovascular Diseases, University of Rochester, Rochester, NY, United States Vascular Surgery Division, University of Rochester, Rochester, NY, United States
a r t i c l e
i n f o
Article history: Received 29 June 2015 Accepted 30 June 2015 Available online 5 July 2015 Keywords: Multidisciplinary Training Cardiovascular disease fellowship
The management of complex cardiovascular disease is rapidly shifting from individual physician based practice towards a multidisciplinary team approach. The plethora of scientific data and the development of new strategies of care led to the wide adoption of the ‘Heart Team’ or the ‘Cardiovascular Team’ concept, where cardiologists work closely with cardiac surgeons, vascular surgeons, neurologists, anesthesiologists, radiologists, interventional radiologists and other specialists to deliver a high-quality cardiovascular care. The importance of this ‘patient-centered’ and not ‘specialty-centered’ approach is well recognized by multiple societies and its adoption is therefore strongly recommended in most contemporary guidelines [1]. The evolution of this collaborative team approach has transformed how cardiovascular specialists interact and provide patient care, and possibly resulted in improved outcomes. Unfortunately, educational models have not kept pace with these changes. In most cardiovascular fellowship training programs, fellows' exposure to other key specialties is limited to didactic lectures, and scattered patient-care related interactions. In the era of multispecialty team approach, this exposure of cardiovascular fellows to their future team collaborators is far from adequate. The most recent guidelines for Training in Adult Cardiovascular Medicine acknowledge the importance of multidisciplinary training but do not provide specific recommendations with regard to its application [2]. The guidelines states that ‘specialists in cardiovascular disease must interact with generalists and specialists in other areas and have knowledge of other specialties to provide excellent patient care. Close
⁎ Corresponding author at: Division of Cardiovascular Diseases, University of Rochester, Rochester, NY, 601 Elmwood Avenue, Box 679C, Rochester, NY 14642-8679, United States. E-mail address: [email protected] (M. Alkhouli).
http://dx.doi.org/10.1016/j.ijcard.2015.06.179 0167-5273/
interaction with cardiovascular/cardiothoracic surgery is of particular importance’. It also states that ‘attendance at multidisciplinary conferences is highly desirable, particularly at conferences closely related to cardiovascular disease, such as conferences on surgery, radiology, and pathology’. Not infrequently, cardiovascular fellows are advised by their mentors to spend time in the operating room, at the vascular clinic and in the cardiothoracic intensive care unit. However, in most ACGMEaccredited cardiology training programs, there are no structured rotations in any of the key cardiology-related disciplines. The planning and undertaking of such rotations are left to the initiative of the fellows, but is rarely achieved due to time constrains, administrative hurdles, political barriers, the need to spend elective time in their future subspecialty, and the absence of goals and objectives for such rotations. These potential issues often lead the fellows away from what can potentially be not only an excellent educational experience but also a great opportunity to foster and enhance a multidisciplinary mentality among trainees. In this letter, we suggest the integration of structured welldesigned rotations in some of the key related disciplines in the curriculum of cardiovascular fellowship training programs.
1. Cardiac imaging Radiologists and cardiologists have different skill sets, and working alongside each other allows a synergistic development of knowledge and expertise. Radiologists are more familiar with cross-sectional imaging, radiation concepts and contrast dynamics, whereas cardiologists bring expertise in clinical pathways, cardiac pathophysiology, and management implications of results. Traditionally, nuclear cardiology imaging has been managed by either radiologists or cardiologists with little interplay. The evolution of cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) imaging and the expansion of their applications, have changed this theme and partially abolished the isolation between the two specialties. The recently published COCATES 4 guidelines (Task Force 4) proposed that training in all components of cardiac imaging modalities (echocardiography, nuclear imaging, CCT and CMR) become integrated in a novel training model; multimodality imaging. These recommendations stem from the increasing awareness of the need for deeper integration of cardiac imaging modalities to facilitate patient-centered imaging, and to provide optimal, safe and costeffective care. However, a practical application of these recommendations would not be possible without serious and strategic collaboration with our radiology colleagues. Also, achieving competency in multimodality imaging may not be feasible with dedicated blocks of time, but rather
M. Alkhouli et al. / International Journal of Cardiology 198 (2015) 134–135
requires a more gradual training methodology. Therefore, creative longitudinal training models will be needed. The initiative to develop these models can be undertaken by motivated cardiology and radiology fellows, but requires continuous support by training directors in both disciplines. 2. Vascular care The increasing awareness of peripheral vascular disease, our improved understanding of its pathophysiology, and the advances in endovascular therapeutics and medical therapy have resulted in the evolution of vascular disease management in the last two decades. Due to the high morbidity and mortality of cardiac disease in patients with peripheral vascular disease, cardiologists now frequently provide primary vascular and cardiac care for these patients. This paradigm change is reflected by the increasing number of peripheral endovascular interventions performed by cardiologists (42% of all peripheral interventions in 2011) [3]. Although cardiologists may have good understanding of atherothrombosis and medical therapy and excellent catheter skills, they do not possess the deep knowledge of peripheral vascular disease that vascular surgeons, who traditionally provided vascular care for these patients, possess. Centers of excellence are now transforming from heart centers to heart & vascular centers, where vascular specialists from multiple disciplines complement each other's skills to provide optimal vascular care. The COCATES 4 (Task Force 9) document recommends that all cardiovascular fellows achieve level I training in vascular medicine. This basic level of training requires the trainees to participate in the evaluation and the management of patients with arterial, venous, and lymphatic disorders in the inpatient and outpatient settings. It also states that fellows should be familiar with the interpretation of vascular imaging reports, and become comfortable in the measurement of ankle–brachial index using hand-held Doppler devices. Often, these requirements cannot be fulfilled without spending dedicated time with non-cardiology vascular specialists. At our center, the vascular surgery rotation is an essential part of the cardiovascular fellowship curriculum. The goals of this rotation are to learn basic concepts behind vascular surgery, clinical decision making in vascular surgical patients, basic nonoperative care, ultrasonography in the noninvasive lab, pre-operative decision making and treatment options for peripheral vascular disease. Fellows with interest in endovascular interventions and interventional cardiology fellows additionally spend one month on the vascular surgery service, during which they perform endovascular interventions in the hybrid operating room and provide pre- and post-operative care for vascular patients. Vascular surgery fellows are offered an optional cardiovascular rotation split between the cardiac intensive care unit and the catheterization laboratory. A joint conference for cardiovascular and vascular surgery fellows is held every month, during which both fellows present interesting cases with background literature. 3. Cardiac surgery The emphasis on the collaboration between cardiologists and cardiac surgeons in a ‘Heart Team’ began after the results of the landmark SYNTAX (SYNergy Between PCI [percutaneous coronary intervention]
135
With TAXUS and Cardiac Surgery) trial were published [1]. This trial underscored the importance of a team approach to provide patients with complex or multivessel coronary disease with the best and most appropriate treatment. The ‘Heart Team’ concept later gained a wide spread attention after the introduction of transcatheter aortic valve replacement (TAVR). The introduction of TAVR offered cardiovascular trainees involved in the procedure with the opportunity to closely interact with cardiac surgeons and cardiac surgery fellows at the weekly TAVR meetings, during the procedure and in the post-operative setting. Although cardiology and cardiac surgery are intimately related fields, fellows in these two disciplines historically rarely interacted with each other and often graduated with inconsistent knowledge of each other's specialty. In the pre-TAVR era the major forum of interaction between cardiovascular fellows and their cardiac surgery peers at our institution was during the joint monthly clinical cardiology/cardiac surgery conference. However, the inception of the TAVR program strengthened the relationship between fellows across the two specialties, improved their understanding of each other's discipline, and promoted knowledge exchange and collaborative research initiatives. Cardiac surgery fellows have since asked to rotate through the catheterization laboratory and experience first-hand the planning and the performance of diagnostic catheterization and percutaneous interventions. Cardiovascular fellows attended surgical journal club activities that were previously limited to surgeons and surgery fellows. Training directors can build upon the positive multidisciplinary environment brought by the introduction of the ‘Heart Team’ concept to design an educational model that will provide both cardiovascular and cardiac surgery fellows with the knowledge and experience needed to transition seamlessly into effective ‘Heart Team’ members upon graduation. The ‘Heart Team’ concept has been gaining increasing momentum over the past decade. Tremendous efforts have been made by administrators and staff members across the country to overcome the challenges and effectively implement this concept at their workplace. However, little attention has been made with regard to early integration of this concept during fellowship training. Introducing solid multidisciplinary training models into cardiovascular fellowship training programs will provide the cardiovascular trainee with invaluable experience, continue to break the historical barriers across specialties, and pave the way to a better multidisciplinary patient-centered cardiovascular care. Conflict of interest None. References [1] D.R. Holmes, J.B. Rich, W.A. Zoghbi, M.J. Mack, The heart team of cardiovascular care, J. Am. Coll. Cardiol. 61 (9) (2013) 903–907. [2] E.S. Williams, J.L. Halperin, V. Fuster, ACC 2015 Core Cardiovascular Training Statement (COCATS 4) (Revision of COCATS 3)Epub ahead of print 2015. http://dx.doi.org/10. 1016/j.jacc.2015.03.017. [3] W.S. Jones, X. Mi, L.G. Qualls, S. Vemulapalli, E.D. Peterson, M.R. Patel, L.H. Curtis, Trends in settings for peripheral vascular intervention and the effect of changes in the outpatient prospective payment system, J. Am. Coll. Cardiol. 65 (9) (2015) 920–927.
