Balancing ACHD and Other Cardiology Specialties – Part 2: The Balancing Act

December 19, 2016 | Jennifer Gerardin, MD, FAAP

This is the second of a three-part interview with five adult congenital heart disease (ACHD) physicians at Emory University and Texas Children’s Hospital. The first article focused on why these ACHD physicians pursued this career pathway and who influenced their decision. The second part focuses on how they balance these sub-specialties.

Maan Jokhadar, MD, FACC, is an associate professor of internal medicine and the ACHD fellowship program director at Emory University. Dr. Jokhadar is Board certified in internal medicine, adult cardiology, advanced heart failure (HF)/transplantation, echocardiography and ACHD.

Wilson Lam, MD, is an assistant professor of internal medicine and pediatrics and the associate program director of the internal medicine residency program at Baylor College of Medicine. He works at Texas Children's Hospital/Texas Adult Congenital Heart Center. He is Board certified in internal medicine, pediatrics, pediatric cardiology, adult cardiology, echocardiography and clinical cardiac electrophysiology (EP).

Anurag Sahu, MD, FACC, is an assistant professor of internal medicine and the director of coronary care unit at Emory University. He is Board certified in internal medicine, adult cardiology, echocardiography, nuclear cardiology, cardiac CT and ACHD and has finished level III cardiac MRI training.

Dhaval Parekh, MD, is now pursuing a fourth fellowship in adult cardiology at Texas Heart Institute. Prior to his current fellowship, he worked at Texas Children’s Hospital as a pediatric interventional cardiologist, ACHD physician. He is Board certified in internal medicine, pediatrics and pediatric cardiology and completed additional fellowships in ACHD and pediatric interventional cardiology.  

Wendy M. Book, MD, FACC, is a professor of internal medicine and the director of the Emory Adult Congenital Heart Center. She is Board certified in internal medicine, adult cardiology, ACHD and advanced HF/transplantation.

Jennifer Gerardin, MD,  is an ACHD Fellow in Training at Emory University, Atlanta, GA.

Are there benefits for an ACHD cardiologist to continue to practice pediatric cardiology or adult cardiology?

WL: Absolutely! I believe all aspects of medicine are closely tied together and I am constantly looking for ways to apply known technology in the ACHD realm. As an example, thinking through the physiology in our adult coronary patients allows us to apply fractional flow reserve concepts in congenital patients. Complex ablations in structurally normal hearts allow us to optimize our techniques in more challenging anatomy. In addition, at many institutions, only practicing congenital cardiology may not meet the requested service demands of the cardiology division. It helps to be flexible!

AS: Yes, of course! ACHD medicine is great, but highly subspecialized. It’s easy to become isolated from your peers if you do this fully. It’s important to work in your primary specialty. This is how you establish relationships with others not just in cardiology, but also other parts of the hospital. You spend a long time training; to not perform clinically in the primary field that you trained in would be a disservice to yourself.

DP: Certainly, it makes you a better overall physician, but the interaction with your colleagues in general pediatrics and cardiology will likely be your ACHD referral source. Also, the sandbox is much bigger in adult cardiology, but the root in ACHD is likely based in pediatrics as this is where the patients start their journey and transition process. It less of a “foreign” language in the pediatric world compared to adult cardiology, but this has a lot of regional variations based on local experts.

WB: We must always remember that our patients are prone to many other issues beyond those directly related to the heart defect. Keeping up with one's primary specialty is very important in managing these complex patients.

How much time do you spend in your primary (adult or pediatric) cardiology specialty?

MJ: I spend about 50 percent of my time in ACHD and the rest is divided between heart failure/transplant, cath lab, echo lab, and the cardiac care unit (CCU). Add to this my administrative/teaching duties for the general cardiology fellowship and ACHD fellowship.

WL: I spend about 35 percent of the year on the inpatient ACHD service while maintaining, on average, a weekly clinic between the Texas Medical Center and one of the Houston suburbs, Sugar Land. The majority of my patient panel is ACHD and a large percentage of these have rhythm issues. But I also see general adult cardiology patients, electrophysiology consults, pregnant mothers with or without CHD, and general pediatric cardiology patients. In addition, I serve about 10 percent of the year on the inpatient pediatric cardiology consult service, usually for Intensive Care Unit patients at Texas Children’s Hospital.

AS: I spend 10 – 12 weeks per year working as an attending in our CCU, read in the echocardiography lab, clinical time on our general cardiology consult service, and of course, advanced cardiac imaging (though most of that is adult congenital).

DP: Most of my time (60 percent) is spent in subspecialty interventional practice in ACHD and pediatrics. I do have an ACHD clinic once a week (20 percent) and the rest is carved out during the week and over the year for both ACHD and pediatric consult services, administrative and educational time. It usually is not that compartmentalized, as on any given day you are likely multitasking on rounds, caths, fellow education, research and, ah yes, Epic’s [electronic medical record.  

WB: I spend approximately 50 percent of my time assisting with management of the heart transplant recipients, including those with prior CHD and those transplanted for more traditional reasons. The other half of my time is spent with my work as director of the adult congenital heart center.

How do you maintain all of your Board certifications?

MJ: I just recertified my internal medicine boards and plan to maintain my cardiology, HF/transplant, and, obviously, my ACHD Board certification. I guess this makes me certifiable.

WL: So, my recertification year for general internal medicine and general pediatrics is 2017. I serve as an associate program director of the internal medicine residency program and have Fellow status of the American College of Physicians and the American Association of Pediatrics. I try to stay active in the medical education with each of the internal medicine and pediatric residencies and the adult and pediatric cardiology fellowships along with the EP and ACHD subspecialties. It can definitely be challenging, but I can let you know how things go when 2018 rolls around. Participating in MOC for one field often translates to another and even this is under transition as of late.

AS: I plan on taking all the recertifying exams, but there are a lot of them. I am not sure that passing an exam after being in a field for 10 or 20 years makes me smarter. I think that we all do it because there is an expectation at an academic medical center.

WB: Thus far, I have continued to maintain four Board certifications. I have felt that this is important due to the significant amount of primary care that we provide to both the ACHD and heart transplant populations.

How do you balance ACHD and your other cardiology subspecialty?

MJ: It is my opinion that one needs multiple skill sets to be an effective adult congenital practitioner, while ultimately working as part of the team. At our institution, we have six adult congenital partners; none of us are pure ACHD specialists. A large portion of my pediatric cardiology partners’ time is across the street of the Children’s Healthcare of Atlanta which obviously complements the ACHD practice. My adult partners practice in various adult fields including general cardiology, heart failure, critical care, and imaging. Having multiple skill sets helps one become a better ACHD specialist.

DP: One of the most important pieces of advice is to avoid fragmentation as much as possible. Create a seamless work environment and comprehensive ACHD program within the context of a larger “heart center”. This allows for a team approach to care and allows for input not just in your specialty but in many others. Many ACHD patients will likely interact with one or many subspecialties of HF, EP, imaging or interventional during their lifelong care. I feel that having a subspecialty can be helpful in terms of the ACHD job market as many centers may not have a need for a full time equivalent ACHD physician.

WB: Due to the way compensation is handled at some academic medical centers, I always felt growing ACHD would be a "passion" supported by my day job. My background in advanced HF and transplantation has served me very well in managing a growing population of adults with CHD and very complex physiology. There are many similarities between the two populations in terms of learning to manage failing circulations. Our success in ACHD here at Emory is largely attributed to my partnership with Michael McConnell, MD, FACC, at the Sibley Heart Center. We were very fortunate to meet each other very early on and develop a strategic plan to grow the center and manage these complex patients together. Without the support of my pediatric cardiology colleagues, we would not enjoy the success that we have today. We have to form similar critical partnerships across multiple departments and divisions within the school of medicine to serve the needs of these complex patients. ACHD is truly a team effort among multiple subspecialties.

WL: It can be tough to balance ACHD with the other cardiology subspecialties, but I think it is important. I attend faculty meetings for pediatric cardiology, planning meetings for pediatric EP, educational conferences for adult cardiology and adult EP, and participate in the interview process for pediatric and adult cardiology fellowships. Setting aside time to stay active and involved is critical to maintaining the personal relationships and the professional fund of knowledge.

AS: ACHD as it stands currently is challenging to do "full-time." As an adult cardiologist there are expectations for other clinical work and I am not sure any cardiologist, adult or pediatric, wants to completely give up working in their original subspecialty.

This article was authored by Jennifer Gerardin, MD, FAAP, an ACHD Fellow in Training (FIT) at Emory University in Atlanta, GA.

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