February 24, 2017 | Bram Geller, MD
Education

During an interview with Bram Geller, MD, a Fellow in Training (FIT) at the hospital of the University of Pennsylvania, Jason Katz, MD, MHS, Director of the University of North Carolina Cardiac Intensive Care Unit (CICU) and Cardiovascular and Thoracic Surgical Intensive Care Unit, discusses the field of critical care cardiology.

Critical care cardiology remains a newer subspecialty within cardiology and has only gained significant traction recently. What made you pursue a career in critical care cardiology, and how did you negotiate the challenges inherent to a new cardiac subspecialty?

JK: I began my training as an emergency physician since I liked caring for a variety of patients, and I enjoyed acute care medicine. As my training in the emergency department progressed, I became frustrated by the lack of continuity through the patients’ acute hospitalization; I found myself going to the ICU after a shift to follow up on patients. Eventually, I switched from an emergency medicine residency to an internal medicine residency program.

During my CICU rotation, I realized that I enjoyed being in the unit and I really liked the acute management in the CICU. I decided that I wanted to build my career around cardiology. I initially went into cardiology fellowship training with the plan to pursue advanced CHF sub-specialization. However, as a cardiology fellow, I realized there were aspects of critical care medicine in the CICU that hadn’t evolved in over 20 years. This turned into a perspective piece on critical care cardiology and led me down the critical care cardiology training path. Formulating the idea of critical care cardiology wasn’t hard, convincing other people that it was reasonable was much harder. Publications in critical care cardiology have made the case for critical care cardiology training easier, but I think there continues to be a need for cardiology divisions to recognize the tremendous clinical value in this specialty.

When you trained in critical care cardiology, how did you create a training pathway?

JK: When I was a cardiology fellow at Duke University, I felt compelled to make critical care cardiology training work there. There was a change in the leadership at Duke, which ultimately allowed me to carve out a joint training program through the pulmonary critical care and cardiology divisions. Initially, I struggled with figuring out the best way to market myself and find a job after fellowship training.

Eventually, I came to UNC since I thought I could craft a niche there. My plan was to be clinically indispensable and build a critical care cardiology program from the ground up. After a lot of collaboration, we have successfully built a solid critical care cardiology foundation. 

What do you think the future will look like for trainees in critical care cardiology? 

JK: It is encouraging to note that there have been a handful of like-minded people across the country, and that this area is gaining popularity through professional societies. Academic and non-academic hospitals are increasingly more interested in this subspecialty, and are recognizing the value critical care cardiology sub-specialization brings. I think hospitals are starting to feel pressure from quality monitoring organizations regarding the need for standardized critical care delivery. At this point we have gotten a lot of people thinking about these issues, which is important. There is also a continued need to prove the value of cardiac intensivists to warrant additional training requirements, board certification, and a widely recognized subspecialty. 

In your practice, you direct the CICU as well as the Cardiac Surgery ICU. Are there lessons in each unit that make you a better doctor in the other unit?

JK: That’s something about my job I really like. I feel comfortable managing both surgical and medical patients. This motivates me in my clinical and research growth. I took over as the director of the CICU early in my career and I did a lot in terms of quality improvement and process improvement work. We converted the CICU to a closed unit, as it had been previously open for decades. We optimized the way we took care of patients with mechanical circulatory support devices, post cardiac arrest and cardiogenic shock. We then developed new teaching paradigms around these critically ill patients.

I was also very involved in optimizing critical care delivery in the Cardiac Surgery ICU. This has now evolved to me taking over the cardiac surgery unit in a leadership capacity. Initially, I was tasked with creating a critical care program for the unit, and had to do it without a lot of resources – staffing or financial. I ended up staffing the unit using an advanced practice provider (APP) model. I have had to train a lot of APPs in this space and did so in a collaborative fashion in a way to optimize trust and communication with the cardiovascular and thoracic surgeons. This is still an ongoing effort to enhance communication, collaboration, and trust. I think the surgeons, nurses and patients are very happy with a model where we now have critical care and cardiology experts contributing to care in the increasingly complex Cardiac Surgery ICU. This model has been financially sound and also resulted in better patient outcomes.

In current cardiac intensive care units across the country, there is a substantial amount of variability in care. This is in contrast to medical and surgical ICUs which have better incorporated certain critical care practices. How can we standardize critical care practices in the CICU?

JK: I absolutely agree that there is too much variability in the CICU, and I think there are a number of different ways to address this. We are at a place where we are still trying to understand the current landscape and practices in CICUs across the country. We will need to understand the landscape better before we try to standardize care. Studying the role of cardiac intensivists and outcomes in CICUs are good initial steps. Patient outcomes are part of what we need to study, but we also have to develop interventions that are cost effective.  The financial environment of cardiovascular care and critical care cardiology are both evolving with the shift towards value based care. We need like-minded individuals to think about optimal ways to deliver care. We also need a society of critical care cardiology, as a sounding board to think about strategies to standardize care, and to better understand current gaps in care.

I am still not sure what the best platform is, but, in my mind, we need to figure this out. We need to move to more concrete evidence-based data. However, showing outcome data in the CICU is challenging, owing in part to such a heterogeneous patient population. Nonetheless, we need better data on outcomes in CICUs and Cardiac Surgery ICUs. We also need to proactively decide how we want this field to take shape, before other vested organizations and payers make significant changes for us. In the future, Medicare and other payers may only reimburse critical care claims if billed by a formal intensivist, but we don’t know exactly what this will look like. It is in our best interest to think about the evolution of this care and the best platform to deliver it. 

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This article was authored by Bram Geller, MD, a Fellow in Training (FIT) at the hospital of the University of Pennsylvania.