September 21, 2016 | William A. Zoghbi, MD, MACC
Career Development

William A. Zoghbi, MD, MACC, is the chair of the department of cardiology, the Elkins Family Distinguished Chair in Cardiac Health at Houston Methodist DeBakey Heart & Vascular Center, a professor of cardiology in the Institute for Academic Medicine, and full member of the Research Institute at Houston Methodist Hospital, in Houston, TX. He is also a past president of the ACC and the American Society of Echocardiography.

Ankur Kalra, MD, FACC, is an early career member in advanced interventional and structural cardiology at Houston Methodist DeBakey Heart and Vascular Center of Houston Methodist Hospital in Houston, TX, a primary academic affiliate of Weill Cornell Medical College in New York, NY.

Ankur Kalra: Your message on July 1 for the new academic year recruits had a significant impact on me. It was about immersing yourself in the field of your sub-specialty and cherishing it. You said, "You have our backs." That was very powerful. It's the beginning of a new academic year; what is your overarching message for the general/advanced cardiovascular fellows?

William Zoghbi: Fellowship is a special time in your career. Fellows should take the opportunity and the challenge to immerse themselves to improve as professionals. I really value fellowship in general, as one starts working as a consultant, elevating your thinking, yet surrounded by expert help that should be tapped. Fellowship is the time to immerse yourself in your specialty. Try to compartmentalize and consolidate— if on general cardiology consults, take every patient encounter and the disease state you are dealing with, and read more about it; get as much information and ask many questions. Similarly, if on an imaging rotation, delve into the technology, image acquisition, and advantages and disadvantages of each imaging modality.

Believe it or not, fellows also have more time to learn, despite packed days, compared with after graduation. There is less "protected and structured" time afterward, and it's upon your drive to continue to update yourself and ask questions. The fellowship experience is very special, as it is the last step in a long career before going out in the "real" world.

AK: A lot of advances have been made in the field of cardiovascular medicine, particularly cardiovascular imaging – your area of expertise – and advanced interventional and structural cardiology, my area of advanced training and interest. When do you recommend first-year fellows to begin identifying their areas of interest to pursue further advanced training in sub-specialties of cardiovascular medicine, if they so desire?

WZ: There in no one answer for all fellows. Some are born with a clear idea of what they want to do; some will keep exploring because they love the field in general, not sure of what direction they will ultimately pursue. This is the time for introspection for fellows as to what is their area of true interest. The most important question is: what is your passion? The most successful people, irrespective of their fields of practice, have pursued their passion. With passion, work is not laborious and innovation flourishes. Passion is the driving force. If you pursue what is popular or what could be popular in 3-5 years, you may not be as successful, as trends change and outcome may be hard to predict. Many fields have evolved beyond our imagination like electrophysiology, imaging and catheter-based interventions; in fact, all areas in cardiology have seen major transformation and innovation since my early days of training. The major drivers have been the innovators with their underlying passion.

My other advice is that the earlier fellows identify their area of interest, the better. Time is precious and rather short. Earlier knowledge will help better organize your training. So if you are interested in cardiovascular imaging, early identification of that interest will allow for better planning of the three years of general fellowship so that the 4th year of advanced training would complement the overall learning. All other areas in cardiology have evolved into needing an additional year or two of advanced training, like interventional cardiology, electrophysiology, advanced heart failure, and now adult congenital heart disease. Furthermore, if the interest is to pursue a career in academic medicine, "the earlier, the better" mantra is even more important, as it takes time to identify a mentor, formulate a research question, develop it, do the study and publish the results.

AK: For fellows interested in cardiovascular imaging, do you recommend an additional one or two years of training, and should the focus be on cardiac computed tomography (CT) or MRI, or a combination of both? Do you think it is feasible to train in both modalities in four years or should it be five?

WZ: Over the years, the field of cardiovascular imaging has become quite broad, complex, and interestingly more essential to both clinical practice and research. The common goal for all the cardiovascular trainees is to know when to order a test, what imaging modality is the best for a particular clinical scenario and what are the advantages and limitations of each. From my experience in the past 10 years of training advanced imaging fellows at Houston Methodist, it is uncommon for someone to be a true expert at all imaging modalities (Level 3 in all). It takes time to train. It is essential for fellows to know what areas they are drawn to and what are they aiming for to plan adequately: Is it conventional echocardiography and nuclear cardiology training, or do they want also to be experts in CMR or cardiac CT?

As trainees are more interested in comprehensive advanced imaging, it is advisable and often necessary to extend the duration of the three-year cardiology program by an additional year or two, depending on the desired goal. If fellows desire a career in non-invasive cardiology, they have to think early on how to structure the 3+1 years, so as to attain expertise in two to three modalities. A true expertise in all modalities would likely require a total of five years. Individuals with such expertise are few, and likely end up practicing in large medical or academic centers to continue being actively involved in this wide spectrum.

AK: The field has progressed so much that I think that in order to be fair to our patients and to ourselves, in calling ourselves experts, we need more time. It takes time to imbibe concepts, let them marinate, and then read and consolidate.

WZ: I started my fellowship around the time when the cardiology fellowship changed from a two-year program to a three-year program. Over time, with the increase in knowledge, required experience and desired expertise, we have added one to two years to the basic three year program, although we have not formally called it an extension of the three-year program. Most cardiologists who are going either into academic careers or private practice need that extra one to two years if they want to differentiate themselves beyond the basic training that a three-year program offers or practice more specialized cardiology. This pertains to interventional cardiology – structural heart being even more specialized, as well as electrophysiology, adult congenital heart disease, and heart failure and transplant cardiology.

AK: Where do you see the field moving in terms of accreditation? None of these fellowships are ACGME-accredited as of yet. Do you see imaging societies, interventional societies or the ACC making a concerted effort to provide accreditation to these advanced fellowships?

WZ: Cardiologists and their professional societies really should make a concerted effort to provide formal advanced training and accreditation at least for cardiovascular imaging and likely soon for structural heart interventions. Part of the underlying hurdles in cardiovascular imaging, in contrast to interventional cardiology or electrophysiology, is that there are several imaging societies that are now mature and have their own boards.

The American Board of Internal Medicine (ABIM) in the recent past thought the process was too complex, and there was resistance against one comprehensive cardiovascular imaging board. I do hope that this resistance ends for the sake of the field, our trainees, and our patients— to formalize under ACGME and ABIM a training path for individuals who are interested in pursuing cardiovascular imaging. It can be modular for specific imaging but should also encompass basic knowledge of all modalities. It should be well structured with a defined curriculum, comprehensive, integrated, easier for fellows to train in, and less expensive.

AK: With regard to Houston Methodist, the sophistication of the simulation laboratory here is completely new to me. Can you tell me more about it?

WZ: MITIE or the Methodist Institute for Technology, Innovation & Education is an amazing and innovative virtual hospital and hands-on clinical training facility for health care professionals. This is a visionary concept that was realized at Houston Methodist over the past decade, and encompasses 40,000 square feet of space totally dedicated to education, simulation and training. In the facility, housed in the Research Institute, there are several surgical suites, all imaging modalities (CT scans, CMR, various simulators for transthoracic and transesophageal echocardiograms), PCI, and even a hybrid room. There are also simulations for management of acute myocardial infarction and shock with camera recordings of the trainees, measuring their perspiration and heart rate during the simulations! This learning environment is great for our fellows and trainees from all the over the country and abroad.

MITIE is the facility we use for our courses on multimodality cardiovascular imaging, and for our fellows' bootcamp (given every August for first and second year fellows from all over the country, fully funded). Many established cardiologists also come here to train in new technologies, and technology innovators use the facility for testing new devices. It is a great Institute for training and lifelong learning—among the best in the country and the world.