November 30, 2016 | Bram Geller, MD
Education

Critical care cardiology is a developing and evolving subspecialty within cardiology. The coronary care unit has evolved from a place where patients with an acute myocardial infarction could complete their infarct under medical supervision, to a complex intensive care unit supporting patients with mixed shock, respiratory failure and dependence on mechanical circulatory support devices. With these increasingly complex patients come new demands on the physicians who care for these patients, both in terms of training and clinical expertise. Training requirements for critical care cardiology are outlined in the literature, but without a robust network of programs offering such training, how do fellows become leaders in the cardiac intensive care unit (CICU)?

Various training models exist, but currently there are very few established pathways to receive this training. As a result, the few fellows that have pursued this training, including myself, must either apply to one of the few existing programs or navigate the complexities of creating a novel program.

I considered applying to one of the handful of established programs that offer additional training for cardiologists in critical care medicine. However, I thought leaving my home institution, where I already have relationships within the cardiovascular department, would hurt my abilities to create new ties between the cardiology and critical care communities. While there are a few fellows at other programs who have created training programs at their own institutions, it has not yet been done at my institution and, as a result, I created a novel pathway for cardiac critical care training.

The American Board of Internal Medicine (ABIM) stipulates the requirements for cardiology fellows who wish to be Board certified in critical care medicine. For certification in both cardiology and critical care medicine, the applicant must already be certified in internal medicine. The total training after medicine training must be at least four years, of which at least 30 months must be clinical. For those adding the critical care medicine training to a dedicated cardiology fellowship, there must be at least one year within the department of critical care medicine, and for cardiology fellows, this year must contain at least six clinical months. The ABIM does not further stipulate which rotations are required, but they do state that the training, “must provide a balanced experience in a variety of critical care settings, and must be broader in scope than the training for any single subspecialty of internal medicine.” They also further stipulate certain procedural skills including: airway management, ventilator management, chest tube insertion, thoracentesis, vascular access and operation of hemodynamic recording systems.

Given that most cardiology fellows have spent sufficient time in the CICU, a significant amount of additional CICU time during the critical care year may not be necessary. After getting advice from other cardiology fellows who have designed similar years at other institutions, and after extensive discussions with my critical care medicine department, we have designed a curriculum for training in critical care cardiology that meets the ABIM requirements and my own educational needs in critical care cardiology. This will include approximately nine clinical months largely in the medical ICU and cardiothoracic surgery ICU with the remainder of the time in the surgical/trauma ICU, neurologic ICU, procedural services and within the anesthesia department for training in airway management. I will also incorporate additional training with the heart failure service into this year. In addition to the procedural skills described by the ABIM, I hope to also acquire training in bronchoscopy, intra-aortic balloon pump placement and extracorporeal membrane oxygenation cannulation.

Currently, cardiology fellows interested in critical care medicine must either create a similar training program at their home institution, or apply to one of the few training programs that do exist. However, for those willing to design a curriculum, there is a great opportunity for leadership and research within critical care cardiology. 

The editors would like to express sincere gratitude to Jason Katz, MD, medical director of the Cardiac Intensive Care Unit, medical director of the Cardiovascular and Thoracic Surgical Intensive Care Unit and Critical Care Service, medical director of the UNC Mechanical Heart Program, director of Cardiovascular Clinical Trials UNC Center for Heart and Vascular Care North Carolina, for his contributions and review of this article.

This article was authored by Bram Geller, MD, a Fellow in Training (FIT) at University of Pennsylvania.