June 22, 2017 | Jennifer Gerardin, MD
This year the combined specialty of internal medicine – pediatrics (Med-Peds) turns 50 years old. Med-Peds physicians have made an impact on primary care and hospital medicine but a quarter of all graduates pursue subspecialty training in pediatrics, internal medicine or a combined fellowship. Many enter subspecialty care with a plan of finding a way to continue to combine these fields and navigating both systems. Within cardiology, adult congenital heart disease (ACHD) has been that field. In the U.S., Med-Peds physicians have been there since the beginning caring for ACHD patients and shaping the field.
There are many variations in training pathways over the years. The first Med-Peds physicians to pursue a specialty in ACHD finished adult cardiology fellowship training after their residency, graduating from Loyola University. Robert Lichtenberg, MD, FACC, was the first Med-Peds trained adult cardiologist to graduate in 1989. Six years later, Frank Cecchin, MD, and Frank Cetta, MD, FACC, were the first Med-Peds physicians to pursue adult congenital heart disease after graduating from pediatric cardiology fellowship. Dr. Cecchin finished training at Texas Children’s Hospital, while Dr. Cetta graduated from pediatric cardiology at the Mayo Clinic and continues to practice in Rochester. In 1999, Curt Daniels, MD, FACC; John Lane, MD, FACC; and Mary P. Mullen, MD, PhD, graduated from combined training in both adult cardiology and pediatric cardiology.
Dr. Cetta explained how his Med-Peds training prepared him for ACHD: “I had a lot of cardiology exposure during first months of my internal med experience at Loyola Chicago. My first mentor in medicine, Bob Lichtenberg at Loyola, turned me on to ACHD. I then switched to pediatrics, and I could hear the heart better! I liked the physiology of congenital heart disease; it wasn’t predominantly chest pain, chest pain, etc.” In these early years of ACHD, many of the initial physicians could practice after graduating their general (adult or pediatric) cardiology fellowship.
Many of these initial graduates mentored and trained the Med-Peds physicians who followed in their footsteps. Since 1989, 76 Med-Peds physicians have graduated from their cardiology training and are currently practicing in ACHD. The majority (45 physicians) completed pediatric cardiology training after residency. Combined fellowship training pathway was the second most popular pathway with 26 graduates. The last combined fellowship trainee graduated in 2015. Texas Children’s Hospital/Baylor College of Medicine has trained the most (15) Med-Peds ACHD physicians. Of those physicians, Wayne J. Franklin, MD, FACC, has trained 10. The other programs that have trained the most ACHD physicians are the Ohio State University, Boston Adult Congenital Heart Program, the Mayo Clinic, University of Michigan, and Children’s Hospital of Wisconsin. In 2015, 43 graduates took the initial ACHD board examine and passed. Med-Peds ACHD physicians have gone on to start programs and practice in 28 states and the District of Columbia. Others finished additional fellowships and certifications in advanced imaging, cardiac catheterization, heart failure, critical care and electrophysiology allowing us to continue to advance the field of ACHD.
Currently, half of the ACHD fellowship trainees are Med-Peds physicians. I am one of the six Med-Peds physicians who will be graduating from my ACHD fellowship in 2017 and part of the first class required to finish a two-year ACHD fellowship. Five more Med-Peds trainees are expected to graduate in 2018.
I am thankful for the people who came before me who paved the way. I asked Dr. Cetta foradvice for future trainees. He said, “Go for it! This is a grossly underserved patient population. Med-Peds Residency training is the ideal training pathway to care for these patients … even if people don’t then complete cardiology training, we need more generalist Med-Peds people to deal with the general internal medicine and systemic disease issues that this aging population faces. Taking care of the babies helps you take care of the old people and vice versa.” I am hopeful that Med-Peds trainees will continue care pursue this underserved field even though training is continuing to become longer.Acknowledgements - I would like to thank Fred “Rusty” Rodriguez, MD; Frank Cetta, MD; Anitha John, MD; Michael Earing, MD; Wilson Lam, MD; Joseph Kay, MD; Michelle Gurvitz, MD; Anne Valente, MD; George Lui, MD; Tim Cotts, MD; Georges Ephrem MD; Karen Stout, MD; Curt Daniels, MD; Yuli Kim, MD; and Chris Learn, MD, for helping me find all of the ACHD Med-Peds Physicians. The rest of the list and statistics was complied and confirmed from the Adult Congenital Heart Association, Doximity, American Board of Pediatrics and American Board of Internal Medicine websites. Thank you to the other Med-Peds physicians that practice adult or pediatric cardiology without managing the ACHD population.
This article was authored by Jennifer Gerardin, MD, an ACHD Fellow in Training (FIT) at Emory University, Atlanta, GA.