Interventional cardiology fellowship training programs have undergone several changes over the past decade. Historically, these training programs limited themselves to PCI.

However, there has been a massive shift lately towards exposure to structural and peripheral interventions, in addition to coronary interventions. As such, training programs are evaluated not only by the number of PCIs performed by each fellow by the time of graduation but also the types and numbers of structural and peripheral vascular interventions.

I was fortunate to train in a program where I had great exposure to coronary and structural interventions, as well as decent exposure to peripheral interventions. Whereas structural interventions felt like breaking into new boundaries, peripheral interventions were not as exciting to me.

Long back-breaking procedures with high radiation exposure were not exactly fun.

In addition, the institutional politics played a huge role in deterring my interest. There was always friction between vascular surgery and interventional cardiology about who should be doing these procedures. At times, this would turn into outright hostility. As a fellow, I chose to stay away from all this as much as possible.

However, my impressions changed when I entered in practice. While there were many different specialties competing for the same patient in large cities (vascular surgery, interventional radiology and of course, us), there was no one to take care of advanced peripheral artery disease (PAD) patients in rural Kentucky.

In fact, if a patient presented with leg ulcer and did not get better with conservative wound care in a few weeks, they would be treated with amputation. Revascularization would not be considered in many cases.

In this setting, interventional cardiologists become the vascular medicine specialists by default. Primary doctors and internists expect help from you (as there is an overlap between risk factors for PAD and coronary artery disease.)

In a lot of cases, even referral to a vascular surgeon two hours away was not an option for some patients. If I did not do anything to help them, they would lose their leg. I found myself taking care of these patients both from vascular medicine and endovascular standpoint.

I started doing these procedures reluctantly, with the intention that I will do whatever I can. The long back-breaking procedures and radiation exposure became totally worth it when I saw legs heal over a period of weeks to months. It was something I rarely got to see during training because patients would follow up with podiatry or wound care after intervention.

Having no vascular surgery or interventional radiology to compete with made all the friction and politics go away. The referring physicians, hospital administration and practice was all aligned to support our program. The pendulum had swung in the other direction!

There are two lessons here for trainees and early career cardiologists. The first lesson is to learn everything you can during training because you never know what you will need during practice. The second lesson is that your practice environment may be very different from the institution where you trained, so do not let politics and friction dampen your spirits.

Let the needs of your patient guide what you need to do to help them, and you will find your perspectives may change.

This article was authored by Syed W. Bokhari, MD, FACC, interventional cardiologist at Saint Joseph Hospital in London KY.