The Heart Team

An important milestone in the field of cardiovascular medicine was neither a new medication nor an operative technique. Rather, it was the embrace of a mindset, which recognized that complex cardiovascular diseases can be better managed using a multidisciplinary approach than by the solitary efforts of a single specialist (1). This emerging alliance, the so-called “heart team,” has been so demonstrably sensible and efficacious in improving patient outcomes that it has been formally adopted within the fields of heart failure, coronary artery revascularization, and valvular heart disease.

As cardiothoracic surgery residents in training, we are fortunate to enjoy the privilege of directly working within and learning from this engagement. In 2007, the Accreditation Council of Graduate Medical Education–the regulatory body of residency training programs–approved a new pathway to train future cardiothoracic surgeons. Known as the I-6 model, the integrated program was designed to train graduating medical students to become board-certified cardiothoracic surgeons in 6 years (2). While the traditional path, which consists of 5 years of general surgery training followed by an additional 2 to 3 years of fellowship training in cardiothoracic surgery, still coexists alongside the I-6 model at many institutions to this day, the I-6 residency curriculum uniquely offers the opportunity for its residents to be formally trained and mentored not only by surgeons, but by cardiologists as well. The benefits of participating in an immersive educational experience are innumerable, but 3 of them stand out in particular: the development of 1) a comprehensive knowledge base in cardiovascular medicine; 2) invaluable professional as well as personal relationships; and 3) a “heart team” perspective.

In this age of specialization, it is challenging to develop a broad knowledge base. In the field of cardiovascular medicine, we must strive to learn broadly, as the pathologies that we aim to treat require multidisciplinary expertise. Replacing a heart valve, for example, is more than an operative endeavor. In addition to anatomic insights, it requires the ability to integrate clinical history and physical examination findings, to medically optimize the physiology, to characterize it accurately using multiple imaging modalities, and to manage critical care. Therefore, to achieve excellent long-term outcomes, it is not sufficient for a cardiothoracic surgeon to master only the operation. He or she must also learn the diagnosis and management of the disease. To accomplish this, the I-6 model was designed so that trainees would learn electrocardiograms from electrophysiologists, echocardiograms from imaging specialists, and complex medical management from heart failure cardiologists. There are invaluable nuances in each of these areas that we are only able to learn as a result of interacting with specialists who have dedicated their careers to the art. Prior to the I-6 residency, such skills would need to be acquired within a shorter time period as a traditional cardiothoracic fellow or as junior attendings.

During the first 3 years (of the 6-year curriculum) in the integrated cardiac surgery residency at the University of Pennsylvania, residents spend 1 year on hospital services staffed by cardiology faculty. We formally rotate through general cardiology, heart failure, cardiac critical care, and interventional cardiology. While on these rotations, we are privileged to have the same active roles as internal medicine residents or, in certain procedural settings, cardiology fellows. During our 3-month rotation in the cardiac catheterization laboratory, attendings teach us the principles of diagnostic and interventional coronary angiography, and we actively participate in performing these procedures. In addition to the value of acquiring wire skills and catheterization strategies that are also useful in emerging endovascular procedures in cardiothoracic surgery, the greatest benefit is learning to interpret coronary angiograms from the perspective of cardiologists. By coming to understand how both cardiologists and surgeons evaluate certain pathology and assess risks and benefits of their approach, we cultivate an intuition for shared decision-making and collaboration, which will undoubtedly benefit patients in the long run. We learn to appreciate how they think, and they learn how we think. This opportunity cannot be overemphasized. Having spent formal time participating in these cases and interpreting angiograms early in our training, we have come to appreciate what it means when the interventionalist thinks the minimally invasive option is not feasible or is too high risk. This allows us to better participate in discussions with cardiology attendings and fellows. When uncertainty exists whether patients would be better served with surgery or medical management, we feel better equipped to contribute to the decision making. This benefit applies to treating all disease processes we encounter where shared expertise improves outcomes for patients.

In addition to the educational benefits of a multidisciplinary curriculum, we are also able to build deep lasting professional and personal relationships with various attending physicians, fellows, and other residents in the field. These relationships are more than just day-to-day interactions. They symbolize the new culture. As I-6 trainees, we cannot overemphasize how formative these relationships have been to our early development and to the forging of an inclusive and multidisciplinary perspective. It leads to the appreciation of cardiothoracic surgery, not as an independent entity, but as one of many critical pillars of the overall clinical picture. The corollary of this perspective is that we become more adept at clinical, research, and even administrative endeavors. When we have clinical or other academic questions, we can reach out to the many colleagues whom we have come to know over the years without hesitation or barriers. We are able to tackle systematic problems that reach outside of our narrow areas of expertise. When we see our cardiology colleagues around the hospital or at professional meetings, we share a genuine sense of camaraderie. We learn to not only share a hospital, but also a community. By the end of our training, collaboration becomes an intuition.

Although this paper highlights the invaluable elements of the I-6 model, it is not intended to suggest a total supplanting of traditional programs. The I-6 path still faces many challenges, such as the enrollment of less mature and experienced trainees directly from medical school, as well as limiting the training from 7 years (5 + 2 years) in the traditional pathway to 6 years in I-6 residency. A benefit of the traditional pathway is that fellows begin their cardiothoracic surgery training with more maturity as physicians and can draw upon their extensive experiences from general surgery residency. Furthermore, the traditional pathway has been time tested over many decades, whereas the I-6 model is undoubtedly a work in progress. Although preliminary reports of its efficacy have been positive, as evidenced by high levels of satisfaction among I-6 trainees and program directors (3,4), there is currently no evidence if this model has improved patient outcomes or surgical training. Future iterations will rely on careful monitoring and robust assessment of individual programs, as well as measuring the long-term success of its graduates (5). The future of the I-6 model will ultimately depend on the degree of commitment among faculty and mentors, both at institutional and national levels, to invest the necessary time, cost, and infrastructure required in training I-6 residents. Suffice it to say, providing a diversified system is crucial at this juncture and for the future.

The paradigm shift that has occurred in cardiothoracic surgery training during the last 10 years with the I-6 model has created an integrated educational approach between heart surgery and cardiology. Although we may still be in the beginning stages of building multidisciplinary curricula as evidenced in the I-6 program, surely the understanding of its efficacy, value, and overall impact will continue to grow. Now, more than ever, the role of the cardiologist in our training is unprecedented, and the “heart team” approach has never been more applicable.