Balancing ACHD and Other Cardiology Specialties – Part 3: The Future of ACHD

March 30, 2017 | Jennifer Gerardin, MD

This is the final segment 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 focused on how they balanced ACHD, adult or pediatric cardiology and additional sub-specialty training. This final part is their advice to trainees and their opinion on the future of the field.

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, ACHD and finished level III cardiac MRI.

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.

What advice do you give to residents and fellows beginning their training? 

MJ - The practice of medicine may prove to become more and more challenging with the rapidly evolving landscape of health care economics, health care administration and delivering health care within the constraints of modern electronic medical record. Many physicians are burning out and losing sight of what led them to the field of medicine. My advice is to never lose passion. This is accomplished by taking the bull by the horns and tackling problems as they arise. If one is not part of the solution, they are part of the problem. Silence is consent, but criticism should always be thoughtful and constructive and not merely complaining.

WL - Work hard at your practice but keep an open mind. You never know when an opportunity will arise that wasn’t along your planned path and ends up leading to countless opportunities to build your career. Learn your guidelines, but verify the primary source and be willing to challenge (in a non-confrontational way) the current line of thinking if you can support a strategy that will improve patients’ lives and health care quality. Medicine is a team sport; sharpen your people skills to collaborate well with the entire team.

AS - The most important piece of advice that I give is to keep an open mind regarding your career path. When we all look back at our applications for medical school, we tend to laugh at the essays that we wrote. Part of this is because we gain not only clinical experience, but life experience. As we grow older, we also come to realize what makes us happy both at work and at home; and often times it is not the thing that originally drove us into medicine.

DP - If this is truly your passion, follow it. Do not let the length of fellowships, the hard work and pragmatism disillusion you. Do not be afraid to veer off course or take chances should you feel it is in your interest. Ultimately, the success of your mentors and training institution is partly measured by yours, and they should want to nurture that. This will be your career for decades to come and should be something you enjoy every day. 

WB - When you think about a subspecialty, think about what life will be like every day for you working in that field. Take stock of what is really important to you and what matters. And remember every morning you will need to get up out of bed and work in that field. That is a lot easier to do if you work in a field that you are passionate about.

What resources do you use to keep up-to-date with new advances in your specialties?  

MJ - Working in an academic environment and learning from the students, residents and fellows help a great deal. Also, maintaining my board certifications forces me stay up-to-date. The accelerating advances in medicine will make staying up-to-date more challenging in the years to come. 

WL - Subscribing to the major journals helps to scan abstracts of the latest hot topics. I receive NEJM, JACC, Heart Rhythm, AJC, Annals of Internal Medicine, and Pediatrics, either as weekly emails or the hard copy journals. Attending national meetings can help with networking and seeing the most updated studies and advances. Since many topics may be similar over a stretch of years, cycling through the major ones every few years is reasonable. For those of us fortunate to practice in large academic medical centers, grand rounds and multidisciplinary conferences can help convey novel ideas and findings.

AS - Being at an academic program, I think, forces you to stay up-to-date. You never want your fellows to know more than you! While challenging, one of the best ways to stay up-to-date is being involved in education and research. It forces you to stay current.

DP - This is likely a multipronged approach with national meetings, journals, participating in research and fellow education and doing this within the platform of an academic center certainly helps. 

WB - The academic environment working with students, residents and fellows is the best way to stay up-to-date. They keep that enthusiasm and passion alive. Our patients spur us on to try harder, do better, learn more and find answers. The people that I am surrounded by everyday are much more important resources then any print or online materials.

With the new training requirements, do you think it is possible to obtain ACHD board certification and additional cardiology subspecialty training?

MJ - This is an interesting question. Two years of ACHD fellowship training on top of additional subspecialty training is asking a lot. I don't think there is the right size fits all. Certainly additional training is a time commitment and financial sacrifice. However, one must follow their passions and the realities of the job market. Having additional skills should open up additional career opportunities.

WL - It is possible, but it will take a lot of time and dedication. The field absolutely needs experts that can bridge additional subspecialties like advanced imaging, intervention, electrophysiology, advanced heart failure or preventive cardiology. Our patients can have the most challenging anatomy and their course does not always follow that of structurally normal hearts. It’s extremely important that experts involved in ACHD care have the expertise to make specific calls that can impact decision-making so we do not rely solely on opinions unfamiliar with congenital heart disease. But I understand the opportunity cost of getting out into practice earlier.

AS - The ACHD two-year certification makes it challenging to do additional sub-fellowship training. After undergraduate studies, medical school, residency and fellowship, time simply catches up with you. This, of course, doesn't include any time taken off for clinical research years, having children or whatever other curveball life throws at you. Most trainees are at the PGY 8-9 level when we graduate. The student loans one acquires during this time as well as the general desire to move on to life after training makes it hard to think about doing more training. You are asking someone to do a medicine or pediatrics residency (three years), then a general adult or pediatric cardiology fellowship (three years), followed by a two-year ACHD fellowship, and then an additional year (or two, if you consider EP or interventional/structural) for something else. It’s simply too much. The two-year ACHD fellowship, as it now stands, also specifically excludes the opportunity to achieve Level 3 training in any field of imaging or intervention. The ACHD fellowship is the only non-procedural adult fellowship that requires two years of training.

DP - I hope so. It makes it very difficult to go through a two-year nonprocedural fellowship and recoup the financial cost. I hope there is a mechanism to obtain at least a noninvasive subspecialty during that time. If one is interested in doing an invasive and ACHD specialty, I recommend that they do the ACHD first so that their recently learned invasive skills are not idle too long.

How do you think the field of ACHD will evolve? 

MJ - We are entering an era of rapid innovations in interventional and structural cardiology that will likely dominate the next decade in the field. Eventually, one must hope that regenerative and molecular technologies will help advance the field further. My crystal ball is in the shop and I will tell you more when I get it back.

WL - The field of ACHD is evolving at an incredible pace. Two decades ago, interventional techniques were at their infancy, and we only imagined we would be replacing valves percutaneously. As technology improves, we should be cath-ing with smaller and smaller access and resorbable material. The challenges of the mitral valve should be overcome for routine percutaneous replacement. Over the past decade, MRI compatibility has been demonstrated for most cardiac implantable electronic devices so more widespread use will allow better imaging that can guide interventional and EP procedures, even at a real time pace. External beam radiation used for treating cancers is being adapted for intracardiac ablation to address arrhythmias. Integrating leadless pacemakers to communicate with each other (perhaps bluetooth?) for dual chamber pacing and with subcutaneous ICDs can hopefully remove the risks of extraction and transvenous infections but give the functionality of today’s devices. Stem cell therapy applied to scaffolding will hopefully allow autologous heart transplants to avoid the risks of immune suppression and rejection while ventricular assist devices become smaller and less thrombogenic, hopefully to support the Fontan circulation.

AS - The field is growing faster than I ever imagined. On the adult side, some of the developments in structural intervention will impact how we take care of our patients. 50 years ago, if you told a cardiologist that we would be placing heart valves through a catheter in the leg, they would have said that you were crazy. Now its commonplace, with devices coming out for tricuspid valve disease, transcaval access for arterial procedures, subcutaneous ICD implantation and leadless pacemakers the range of options for patients with CHD seems nearly limitless. ACHD will be at the forefront of using these new and innovative technologies.

DP - ACHD will evolve similarly to what pediatric cardiology is today. As the complex ACHD population continues to grow, there will likely be some compartmentalization within the general cardiology community and ecosystem to manage their subspecialty needs will sprout. This is beginning in some of the larger centers where there are ACHD imagers, EP, HF and interventionists under one roof. 

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

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