Training in ACHD: An Interview With Thomas M. Bashore, MD, FACC

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Jordan D. Awerbach, MD, MPH interviews Thomas M. Bashore, MD, FACC, who is a professor of medicine and senior vice chief of the Division of Cardiology at Duke University Medical Center. Bashore developed the Valvular Heart Disease and Adult Congenital Heart Disease programs at Duke while also showing an unparalleled commitment to teaching and mentoring Fellows in Training (FITs). Bashore previously served as the cardiology fellowship program director for 12 years and won the annual cardiology fellow teaching award so many times that it was eventually renamed the Thomas M. Bashore Annual Cardiology Fellow Award For Faculty Teaching in his honor.

JA: How did you first become interested in caring for adults with congenital heart disease?

TB: I became interested when I got involved with the development of the Valvular Heart Disease Program at Duke, as caring for adults with congenital heart disease seemed like a natural extension of that interest. Arthur Garson Jr., MD, MPH, MACC, was the chief of pediatric cardiology in the early 90s and was very receptive to developing the adult congenital program with adult cardiology. Norman S. Talner, MD, FACC, was also chief of pediatric cardiology and retired in Chapel Hill after many years at Yale. They were both wonderful to work with and wanted the program to develop. It was their cooperative spirit that made it fun and provided the structure to make it happen.

JA: You started the Duke Adult Congenital Heart Disease (ACHD) program when the field was still in its infancy. What was it like starting the program at that time?

TB: We felt that the best way to organize the program was to have the clinic and cath lab include both a pediatric and adult cardiologist. Martin O’Laughlin, MD, was recruited from Houston to run the pediatric cath lab and was simply a terrific person and interventionalist. We all learned from one another. Norman S. Talner, MD, FACC, was very involved with the pediatric boards and we worked out a deal with the American Board of Internal Medicine (ABIM) wherein a fellow who wanted to do ACHD could train for two years in pediatric cardiology, two years in adult cardiology and complete one year of research counted toward the adult cardiology training requirement. In that manner, fellows could be certified in both pediatrics and adult cardiology and sit for both boards. We were successful in training some first-rate FITs as almost all remained in an academic job once they completed the program.

JA: What do you think has changed the most about the field over the time?

TB: The number of children with more complex congenital lesions that reach adulthood has dramatically increased as the surgical results have improved. The more widespread use of magnetic resonance imaging (MRI), improvements in invasive electrophysiology and development of percutaneous closure devices and valve replacement have all had significant influence, as well. There is now a national awareness that there are many more adults with congenital heart disease than children and a realization that there are an inadequate number of trained cardiologist to care for these patients. This realization led to the development of a formal ABIM training track in ACHD.

JA: What aspects of ACHD care do you think still have a long way to go?

TB: We have very little evidence-based data. In particular, there is a paucity of information on the treatment of right ventricular dysfunction and whether it is the systemic ventricle or subpulmonary ventricle. We desperately need a national database to pool the information on all these patients from multiple institutions since it is a heterogeneous group. Unfortunately, there has never been funding on the national level for this, partially because it would require long-term follow-up to better understand the impact of what therapies we have. Because data are lacking – even though we have adult congenital guidelines – the level of evidence is “C” for almost all of the recommendations. Many patients also struggle with obtaining insurance and social support necessary for optimal care, which becomes a frustration for both them and their providers. It often leads to delays in care and unnecessary worsening of their condition. The cruelty of our health care system can play out dramatically for many wonderful patients.

JA: What are the ingredients for a successful ACHD program today?

TB: The secret to a successful ACHD program is to have buy-in from pediatric and adult cardiologists and cardiovascular surgeons. This is one subspecialty area where cooperation is critical. Both the adult and pediatric physicians bring different perspectives to the problems patients present and it does not work without dedicated faculty, nursing and administrative support. A successful program also needs to have advanced imaging techniques and state-of-the-art interventional options as patients and referring doctors must know they are getting the best care. Hospital administration must also appreciate the complexity and uniqueness of this patient population and provide adequate funding to make the program viable. Most practicing cardiologists are happy to have a referral center to send patients, so a successful program can provide an important clinical service that is not in direct competition with practicing physicians.

An established ACHD program can provide important visibility for any health system. Transition from the pediatric cardiology to the adult congenital practice is still incompletely accomplished and a viable program needs to facilitate this transition. Philanthropy can play a major role, especially in helping fund trainees interested in developing the skills needed for a career in ACHD. We are fortunate that the Tom Anstrom Fund was established to help fund a fellow, as we suspended training fellows for a time because of funding issues. It is important that there is a commitment from the health system to adequately staff and fund the ACHD program.

JA: What advice do you have for FITs interested in pursuing ACHD training?

TB: This is an incredibly rewarding group of patients to care for and there is a great need for more formally trained faculty and practice physicians. Patient problems are often complex and patients are incredibly grateful to find nurses and physicians who understand their issues. Few, even in large medical facilities, have individuals with the appropriate skills. In general, the clinical focus of ACHD training should be in acquiring either noninvasive skills (echocardiogram, MRI, computed tomography angiography, cardiopulmonary exercise testing, etc.) or invasive skills so that percutaneous treatment options can be offered. Other areas of concentration that provide viable career options include pulmonary hypertension, electrophysiology, heart failure and health care delivery. If you want to take care of appreciative patients and have a challenging career where you can make a major impact, you should consider training in ACHD!

This interview is conducted by Jordan D. Awerbach, MD, MPH, Thomas Anstrom ACHD Fellow in Training at Duke University in Durham, NC.