RESPONSE: Hybrid Training for Interventional, Heart Failure, and Critical Care Medicine

In his treatise, Rules for the Direction of the Mind, the French scientist and philosopher Rene Descartes defined the concept of perspicacity as a penetrating discernment or clarity of understanding and deep insight (1). As a trainee, my mentors suggested that achieving perspicacity is a primary objective for fellowship training and meant spending time focused on study and practice to thoroughly understand advanced principles of patient care and research associated with a discipline.

Heart failure continues to be a dominant medical problem affecting nearly all aspects of cardiovascular medicine with many unanswered questions and challenges. As the prevalence of heart failure grows, it is evident that nearly every patient seen in the catheterization laboratory either has or is at risk of developing heart failure. Interventional cardiology offers the opportunity to apply technical solutions to key aspects of heart failure physiology across the clinical spectrum from outpatient to inpatient settings. From my perspective, the combination of interventional cardiology and heart failure was a natural fit and has since emerged as an exciting field with endless potential to advance patient care and innovation related to hemodynamics and device-based approaches for heart failure secondary to reduced or preserved ejection fraction, coronary disease, valvular heart disease, systemic hypertension, pulmonary hypertension, right heart failure, cardiogenic shock, or myocardial infarction (2,3).

At the time, the challenging question was how to effectively train in both complex subspecialties without emerging as a half-baked interventionalist or heart failure specialist. The marriage of electrophysiology and heart failure had recently failed to thrive, because the relationship was built heavily on a single pathway of innovation related to cardiac resynchronization and defibrillators. One way to avoid this fate was to commit dedicated training years for each subspecialty upon completion of a general cardiology fellowship program. This approach offered the opportunity to achieve that penetrating clinical and academic insight necessary to ensure optimal patient care and to advance the field.

In the current era, critical care is the new heart failure. This fact is only made more obvious by the coronavirus disease-2019 (COVID-19) pandemic, where the sheer number of critically ill patients quickly outpaced capacity in hospitals around the world. Dr. Panhwar and colleagues propose a new training pathway that incorporates critical care training during a single year of interventional cardiology fellowship for select high-volume programs where the required coronary procedural volume can be rapidly attained, thereby leaving time for critical care training. From one perspective, this proposal makes sense, as the authors suggest that many patients requiring interventions are critically ill, and having interventionalists with some exposure to critical care medicine may improve patient outcomes.

Once again, the fundamental challenge is how to avoid generating half-baked interventionalists and critical care specialists who lack comprehensive technical skills and penetrating insight into either subspecialty. Hospital administrators should be wary of any hybrid specialist who lacks dedicated training in all aspects of the amalgam. Several well-established critical care training pathways leading to board certification offer as much flexibility as possible without sacrificing educational quality (4). A more likely solution for aspiring “interventional-intensivists” may be to merge critical care and general cardiology training, thereby allowing for dual-board eligibility prior to initiation of advanced training in interventional cardiology. Interventional programs are already incorporating complex coronary and structural techniques, which require focused training that extends beyond simply achieving the minimum number of procedures required for board eligibility. Hybridized programs are a terrific opportunity to change the way we think and practice. However, given the complexity of managing patients with interventional, heart failure, or critical care problems, there is no room for short-cuts in education. The most impactful quote by Descartes summarizes the direction for aspiring hybrid physicians: “Cogito, ergo sum,” or “I think, therefore I am.”