June 22, 2016 | Jeremy Nicolarsen, MD
Career Development

Careers in adult congenital heart disease (ACHD) are on the rise. In the second of this three part interview series, we’ll look at ACHD care from the vantage point of the early career ACHD Program Director. In this installment, we’ll hear from Yuli Y. Kim, MD, FACC, director of the Philadelphia Adult Congenital Heart Center at Hospital of the University of Pennsylvania and Children’s Hospital of Philadelphia (CHOP), and Ali N. Zaidi, MD, FACC, director of the Montefiore Adult Congenital Heart Disease Program (MAtCH) at the Montefiore Einstein Center for Heart & Vascular Care, Montefiore Medical Center, and The Children’s Hospital at Montefiore, Albert Einstein College of Medicine in NY.

After an internal medicine (IM) residency and cardiovascular disease fellowship, Kim completed a two-year ACHD fellowship at Boston Children’s Hospital and then found her way to Philadelphia to take over at the helm of an established, yet still developing ACHD program. Zaidi trained in internal medicine and pediatrics (Med-Peds) followed by an IM Chief year before embarking on a five-year combined fellowship in pediatric cardiology and cardiovascular disease, with an emphasis on ACHD and imaging. He then worked for three years on faculty at the Columbus Adult Congenital Heart (COACH) Program before moving to New York City to take on his current leadership role. Both are from the newest guard of ACHD physicians and are well-respected and making names for themselves in the field of ACHD.

Training in ACHD

There are many training paths to a career in ACHD and leaders in the field come from both pediatric and IM backgrounds. Do you have any suggestions for ACHD training?

YK: I come from an adult-oriented training background. When I entered training, ACHD was not a career decision for which I planned. I’m not saying the way I trained was wrong, but one really great way to prepare for ACHD is a Med-Peds residency followed by a pediatric cardiology fellowship. Having now worked in two children’s hospitals and seeing what the issues are on both sides of the street, that combination of training, that background, is well-suited for ACHD. That being said, my adult cardiology training has been invaluable for both inpatient and outpatient care, especially with the older, sicker patients with comorbidities.

AZ: I thought the best way to train with my Med-Peds background was to do both fellowships. I took a long route to get here, but having said that it was the right way for me. If you have the opportunity to come from both adult and pediatrics backgrounds, you speak both languages. You can easily talk about coronary disease in adults, nuances of ACHD, or a newborn with single ventricle physiology. You speak all of these languages and it’s absolutely wonderful – the perfect amalgam to be a well-rounded ACHD physician.

What experiences enhanced your training and what did you wish you had learned when you had the opportunity?

YK: I felt perfectly comfortable taking care of sick adults and adult cardiology issues, such as adult heart failure, and having an IM background helps you manage multisystem disorders and how they relate to one another, which is the cornerstone of ACHD. My weakness though, as that of many IM-trained people in ACHD, was the anatomy. This was helped tremendously by focused training in echo and magnetic resonance imaging (MRI) during my ACHD fellowship at Boston Children’s. I would have loved to have done a year of pediatric cardiology. To not think about adults but instead think about newborns, their anatomy and physiology, and about the decision-making process involved in taking care of the neonate with congenital heart disease would have been invaluable. You can get some of that from surgical conferences, but it’s not the same.

AZ: Having trained across both adult and pediatric cardiology, understanding ACHD became easier. At the end of the day you still need some skillset (in addition to ACHD) that’s going to hold you together, be it echo, MRI, or cath. When I started fellowship I wasn’t thinking that way but by the end I was. I wanted to be a well-rounded ACHD physician, but I also realized that you have to do something else once you look for a job, something in your back pocket. Your day job is going to be ACHD, but can you do something else that will make you more marketable?

Mentorship

How did you find your mentor(s) in ACHD?

AZ: First, find the best fellowship program that you can find. Identify the program but more importantly, identify the mentor. I met my mentor, Curt J. Daniels, MD, FACC, when I went to Ohio State in 2004. Curt has been singularly instrumental in guiding me over the years. Over the course of my time, I found others who mentored me as well. It’s not that you want to emulate them in every facet of life, but you pick and choose their admirable qualities. Your formative years of fellowship are based on who you work with and what you see. If you don’t find a good mentor, then you’re missing out on a big slice of life. Their support and guidance becomes essential to how your career will get shaped, like Curt has helped shape mine.  

YK: Our field is relatively small, and it may be hard to find someone in your practice who does ACHD. I’ve always looked to who’s around me and who I look up to. My first mentor who continues to mentor me to this day is Michael J. Landzberg, MD, FACC.  He really played a formative role in teaching me about the field and in my mind sets the standard.  My current mentor is Meryl S. Cohen, MD, FACC, a pediatric cardiologist at CHOP. I meet with her on a monthly basis and she has been really instrumental in advising me on my career, balancing work and life, and she’s also my sounding board. Finding her was very important to me because, as a woman in cardiology, it can be challenging and she is an absolute role model. My advice to fellows is to find someone you not only look up to, but someone who is willing to support you regardless of what their background is.

What is an important lesson you have learned from a mentor?

YK: Many of my lessons came from Boston Children’s. I learned by watching my attendings function at two hospitals. I didn’t have sit-down didactic sessions about how to run an ACHD program but I learned by observing. I watched Mike manage a complex program comprised of two strong centers of excellence that he clearly put blood, sweat, and tears into building. That was probably the best training I had for my job now, which was just observing.

What have you learned as you have become a mentor to others?

AZ: I’ve been out five or six years now. I’ve mentored or tried to mentor people as much as I could. I always say that mentorship is a really big role. You’re trying to mold someone’s career as they’re coming through residency or fellowship or a subspecialty fellowship. It’s not an easy role to be in. In some ways you’re responsible for the career of that person. I’ve learned that the success of your mentee is your success – you’ve done a good job if the person you mentored is successful.

Careers in ACHD

What does a typical workweek look like for you?

YK: I have clinic two and half-days per week and spend a half-day reading echos. 10 percent of my time is protected for administrative work and program management, and I’m on an academic track so I have a day that is protected for research. I’m on call every three weeks for ACHD and attend two weeks of the year on the consult service and two weeks on the CCU service.

AZ: I have a very busy workweek but that happens when you try to build a new section on your own! It’s expected. I do three full days of clinic. Two days are purely ACHD and one day is a split between ACHD and PH. There is one day I dedicate to imaging – echo or MRI/CT. Once a month I do a transition clinic at the children’s hospital where I see patients who are still in pediatric cardiology and are being transitioned to ACHD. That leaves me with one day that I invariably use for administrative time and research, which is important. Aside from this, I take solo call for ACHD and do about eight weeks of inpatient CICU time as an attending. 

As an ACHD Program Director, or as any academic clinician for that matter, do you have advice for advancing your program or career amidst a busy clinical workload?

AZ: When you build a program you need time set aside for programmatic development. You’re meeting with people – either trying to build bridges with other sub-sections within adult or pediatric cardiology or even outside cardiology, or you’re meeting with marketing, media or referring physicians. There are a lot of programmatic nuances that I have to accomplish in a day, aside from catching up on all of my clinical responsibilities. At the same time, you are trying to be productive from a research standpoint, so one learns how to multi-task very quickly. Trust me, your time goes very quickly. You have to protect your administrative or research time, if you have it.

YK: I have protected time, but I can tell you, for the first couple years that time was not being used. As a fellow, you’re so busy running around taking care of the patient and you think, sure, I’ll take that on or I’ll do this. In my first couple years, it wasn’t that my protected time wasn’t protected – I didn’t protect it! My advice to you and others is that if you are given this time, really make it a priority to protect it. No one is going to do that for you.

Program Development

What made you choose to run an ACHD program?

AZ: In ACHD there really are two jobs. You can go and join a program that has two or three people and you’re going to be the 2nd or 3rd or 4th, and that’s completely acceptable. Every person wants a different role in life. OR, you’re going to do what I’m doing (program directorship) and build something from scratch. Often, there’s a pediatric group or an adult group doing ACHD and there are some patients here and some patients there, but what’s needed is someone to gel it together and grow a program, build a section, and take it forward. That’s the position I took when I came to New York, and New York can be a challenging place in which to work.

YK: I didn’t come into this wanting to run a program. This was not on my to-do list after completing fellowship. But this opportunity presented itself and after multiple visits and some soul-searching, I felt confident that I would have the support from both CHOP and Penn to make this work. If that support weren’t there from my chiefs, I definitely would not have chosen this path.  

How can you build a successful program?

YK: Hiring people into your team is probably one of the most important things you’ll be allowed to do as a director. Building the team is very hard. You don’t get any training on this – you ride through the ranks from medical student to intern to resident and you don’t get any opportunity to manage anything, and once you’re in a program directorship position, no one teaches you how to manage people, no one teaches you to manage teams.

The guiding principle for me that has worked well is to always make your decisions based on patient care. If you do that, then your choices and the decisions you make really can’t be questioned. If people understand that what you want to do is help patients and give them the best care you can, then all of the challenges that come with working with various factions in two different institutions come secondary. You should feel comfortable knowing that your decisions are based in clinical care.

AZ: You need the right people working with you to build a section. You can’t do ACHD, especially in a new program, if there isn’t a solid landing zone for the patients. This is essential to provide the best care possible. New programmatic builds can be difficult. You can’t say, “I’m the ACHD doc and it’s just me and you have to send me patients.” It doesn’t work like that. You need infrastructure and you need leadership support.  You need to develop a referral base both internally and externally. You need to base your decisions on what’s right for the patients. You need the right people in the right places. Curt always taught me it should never be looked at as just a clinic, it’s a program – and it takes tremendous time, effort and support to build it into that.

If you take on a role like this, look at your leadership. Are they going to support your vision? Because if they’re not going to, you could be the best ACHD doc but you’re not going to go anywhere with it.

What have you enjoyed most about program leadership?

AZ: If you’re successful it can be fun because you start seeing the product that you are putting so much effort into take shape. It’s a bit of an abstract concept, but you begin to see that what you’re doing is the right thing for these patients and the care they are getting is better. If you do it right for the patients, there’s a feeling of gratification, not that anybody needs to come and thank me, but a feeling of internal gratification that this is working out and patients are getting the care they need. The teaching and research come with that.

YK: The most rewarding part of program leadership is watching this thing take shape and grow. It’s like parenting and despite its headaches, struggles, and ups and downs, it is extremely gratifying at the end of day. I really love working with the team and watching them each move it forward in their own ways is terrific to witness.

Future of ACHD Care

What does the future of ACHD care look like?

YK: It’s going to be a collaborative care model. There are so many of these patients floating around. I don’t think it’s possible to take care of all of them without some collaboration with our colleagues in pediatric and adult cardiology. Also, I worry about patients who don’t have access to ACHD care. Unlike the northeast corridor, where every state has an ACHD program, there are many parts of the country that are underserved. How can you provide routine care for someone who doesn’t live close by? Access to care, including the use of telemedicine, will be important, and a collaborative care model will help with this as well.

AZ: ACHD is a growing field. It’s growing in every state and in every city. You are seeing more patients on the adult side, but it will always grow more from within the realms of pediatric cardiology. The collaboration across both fields will continue to grow. If you take a pie chart that represents pediatric cardiology and you divide it into sections, the slice that’s growing the most is ACHD. If you make the same pie chart but this time represent the adult side, it is dominated by coronary disease and heart failure, but now there is a slice that represents ACHD that was not there before.

You’ll see more growth in the field, more collaboration, and there’s going to be more research and multicenter studies. There are going to be more people training in the field. That’s really what is needed – more people who are exclusively trained to do this down the road.

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This article was authored by Jeremy Nicolarsen, MD, a fellow in training at University of Colorado Hospital and Children’s Hospital Colorado in Aurora, CO.