September 29, 2017 | Ahmad Masri, MD
Education

Imaging has become an integral part of cardiology. Although often times not thought of as an imaging modality, the first true form of cardiac imaging was selective coronary angiography (Mason Sones, 1958) that revolutionized our specialty. Decades later, non-invasive means of imaging the heart have surfaced, such as echocardiography, nuclear imaging, computed tomography and cardiac magnetic resonance imaging.

Imaging has become an integral part of cardiology. Although often times not thought of as an imaging modality, the first true form of cardiac imaging was selective coronary angiography (Mason Sones, 1958) that revolutionized our specialty. Decades later, non-invasive means of imaging the heart have surfaced, such as echocardiography, nuclear imaging, computed tomography and cardiac magnetic resonance imaging.

In the early days of these imaging modalities, physicians and fellows in training (FITs) pursued a path that led to specialization in a single modality. Our interactions and training with these experts has been monumental in augmenting our understanding of cardiac disease. Since then, these fields have matured and evolved with an ever-increasing role and application in the clinical arena. This has led to a need for clinicians to specialize in more than one imaging modality. In the early 1980s, articles began to appear that coined the phrase “multimodality imaging,” which has led to the birth of this new specialty within cardiology. Since then, many multi-modality imaging programs have opened their doors and successfully trained a new generation of FITs.

However, this specialization track remains somewhat controversial. Many FITs interested in this field find themselves seeking advice from their respective senior mentors and colleagues on how to navigate this ever-expanding field. Many cardiologists firmly believe in focusing on one imaging modality, perfecting one’s understanding of it and its applications, achieving the highest COCATS level of training, conducting research, and improving patients’ care. Alternatively, a “jack of all trades” approach with broad based knowledge in the different modalities is often advocated. However, many will find it difficult to follow all the advances, literature and changes in our rapidly evolving field. Others support the role of multi-modality imaging in furthering patient care through the “unbiased” selection of the best modality for each specific patient’s situation.

FITs should view these career options as complementary rather than alternatives. There will always be a role for experts in each of their respective modalities to direct laboratories, who’s jobs go well beyond clinical care and extend into the technical details, managing lab members, and ensuring highest quality of studies performed all whilst maximizing patients’ care and experience. On the other hand, a multi-modality imager represents a much-needed non-invasive cardiologist who is patient-centered, cost effective and able to conduct comparative effectiveness research. In essence, a multi-modality imager’s role is more patient-centered rather than modality-centered.

Currently, no one modality has complete monopoly over a particular disease process. While comparative effectiveness research sometimes paints different modalities as competitors, in essence, all these modalities are complimentary to one another – situation-specific and patient-centered. This has led to the production of disease-oriented multi-modality imagers, where the goal is not to obtain the highest COCATS level of training in all imaging modalities but, rather, to train in all aspects of imaging for a specific disease entity to be used for clinical care. Cardiac amyloidosis is an example where echochardiograhy, nuclear and CMR are paramount tools for the diagnosis and management of this disease. Thus, it is natural for an FIT specializing in a disease process to acquire knowledge in all of these modalities. Combining clinical, imaging and research training for a specific disease process makes those FITs the experts that their patients’ need.

Ultimately, there is no right or wrong approach, but FITs interested in cardiac imaging need to better understand their individual goals, become better informed, and be able to confidently select one of these pathways that would be the best fit for them.

This article was authored by Ahmad Masri, MD, Fellow in Training (FIT) at the University of Pittsburgh Medical Center.