Interview with Sean Van Diepen, MD, MSc
AK: What drew you to critical care cardiology?
SVD: While I was rounding in the coronary care unit as a cardiology resident, I saw care gaps in critical care best practices and perceived a clinical need. There were huge gaps in preventive therapies; for example, best practices for sedation or ventilator management were not being routinely applied. My interest was born out of this need and I thought I could make a difference.
AK: What was your pathway into critical care cardiology?
SVD: When I raised the possibility of doing a critical pathway with other physicians, both cardiology and intensive care unit (ICU) doctors, people were polarized by the idea. My divisional director in cardiology thought it was a great idea; however, other staff members did not see the value added. On the ICU side, the responses were equally polarized. Some said, “this is a very novel idea and I think you can do a lot of great work,” while others explained that they did not want to train a “super-cardiologist.” There was a lot of negativity. However, that negativity only solidified my desire to pursue this field, and to help improve the recognition that ICU training could potentially improve outcomes in a tertiary care setting.
AK: Considering the polarizing responses you received, how did you approach obtaining mentorship?
SVD: My best advice regarding mentorship is that you do not need just one mentor; I have a number of mentors that cover all facets of my practice. I have multiple clinical mentors, research mentors and life mentors. Trainees should develop a mentorship team. Furthermore, mentors do not have to be content experts. In fact, none of my mentors are critical care cardiologists; they are from both cardiology and critical care, but none of them do what I do. Mentors do not have to be doing exactly what mentees do.
AK: What are your suggestions for fellows interested in critical care cardiology without a dedicated training pathway at their home institution?
SVD: There are two paths that fellows can take: (1) speak to as many other programs that have developed pathways, or (2) develop your own. When I went through my training, there were no dedicated critical care cardiology pathways. Developing your own program is extremely difficult; it took me about 18 months to establish a critical care pathway. If you are creating your own training pathway, it is very important to have an understanding program director.
AK: Tell me more about how you developed a critical care pathway for yourself.
SVD: The biggest challenge I faced was a lack of appreciation of the potential role a dual-trained cardiologist in cardiology and critical care could play. Very few people had done this previously, so there was no clear training template and I had to develop my own with the support of a few forward-thinking mentors.
In Canada, to get critical care boarded you need to spend two dedicated years in the field. Although, to be a cardiac intensive care unit (CICU) intensivist now, there are one-year programs. I started with the one-year program and then transferred into the full two-year program. When my training began, I thought I only wanted to be a CICU intensivist, but then realized I wanted to work in both the CICU and ICU environment. I was also one of the first people in Canada to do critical care cardiology, so I felt that being dual-boarded would go a long way for future initiatives.
AK: You talked about the “value added” from dual-trained cardiologists. Tell me more about that value.
SVD: The value-add is in all the non-cardiology fields. From a training perspective, the greatest learning is in the non-cardiology rotations, such as working in the medical and surgical units, working with anesthesiology, learning bronchoscopy skills and more. Most trainees at the end of fellowship can manage cardiac specific problems. The value of critical care training is dealing with all the co-morbidities and multi-organ system failure.
I think the biggest value added to the CICUs after getting critical care training is the development of new protocols. We have adopted best practices for prevention of ventilator associated pneumonia, stress ulcers and mobility. These initiatives are now entrenched in background flora of the CICU, and probably have the biggest impact on patient outcomes.
AK: You talked about learning to perform bronchoscopies. Are there other non-cardiac procedures you do?
SDV: Other non-cardiac procedures I perform include intubation, bronchoscopy, open and percutaneous chest tubes, paracentesis, lumbar punctures, renal replacement therapy, intermitted dialysis and mechanical ventilation.
AK: What do you think are the most interesting unanswered questions in critical care cardiology?
1. What are the best care critical care prevention practices in the cardiovascular population?
2. What are the optimal mechanical ventilation settings for both heart failure and cardiogenic shock patients?
3. What is the optimal vaso-active selection during cardiogenic shock?
4. What is the optimal in-hospital care of resuscitative arrest patients?
AK: Do you have any final words of wisdom for cardiology fellows with an interest in critical care?
SVD: While critical care lifestyle is demanding and includes a lot of late nights and overnight calls, it is an extremely rewarding career.