July 18, 2018 | Ahmad Masri, MD & Mourad Senussi, MD
Education

The first coronary care unit was established in the 1960s in an attempt to provide more intensive care and close monitoring to patients with acute myocardial infarction. The surprising part is that it took decades for the discipline of critical care cardiology to emerge. The introduction of early reperfusion therapy for acute myocardial infarction has led to a change in the landscape of coronary care unit to become more inclusive of patients with a wide range of acute cardiovascular and medical illnesses. Such a change introduced the need for a cardiologist with additional skills that are not routinely acquired as part of a cardiology fellowship. To shed some light on training in critical care cardiology, I sat down with Mourad Senussi, MD, an exceptional third-year Fellow in Training (FIT) at the University of Pittsburgh. Senussi followed a non-traditional route, training first in critical care medicine and then cardiology.

Share with us a brief overview of your journey in medicine so far.

I graduated from the University of Tripoli School of Medicine in Tripoli, Libya. Then, I then completed an internal medicine residency training at Saint Joseph Hospital in Chicago, IL, followed by a two-year critical care medicine fellowship at the Cleveland Clinic. Currently, I am a third-year cardiology FIT at the University of Pittsburgh Medical Center in Pittsburgh, PA.

Why did you go into critical care medicine? Was your plan always to become a critical care cardiologist?

During my incipient stages, I knew all that I would eventually end up doing critical care medicine. Like many who go into this specialty, I was initially drawn to the dynamic and action-packed nature of the field. However, as I matured, I quickly realized that the truly fascinating aspects of this field were not only the procedures but rather the thoughtful and multidisciplinary approach to managing this vulnerable population. During my critical care medicine fellowship I had an amazing experience where I was exposed to a high volume of complex critically ill patients. That exposure is where I developed an insatiable appetite for hemodynamics, resuscitation and point-of-care imaging in the critically ill. I found deficiencies on both sides of the aisle when it came to managing critically ill cardiac patients. My passion for hemodynamics and a better understanding of this unique patient population drove me to pursue further training in cardiology. Looking back, it has been the best decision I have ever made. My better understanding of ischemia, arrhythmias, heart failure, valvular heart disease, echocardiography and advanced circulatory support has made me the more consummate intensivist I have always wanted to be. I realized that a cardiac intensivist is a true distinct entity.

What skills do you think critical care training adds to a cardiologist?

Most importantly, it provides an all-encompassing mindset when it comes to managing patients with a multitude of comorbid conditions. Having a comprehensive understanding of sedation, analgesia, respiratory failure, mechanical ventilation and non-cardiac causes of shock can only add to patient care.

How do you compare your traditional training of two years in critical care vs. the current proposed training of one year after cardiology?

I wanted to truly immerse myself into critical care and felt that the two-year fellowship was right for me. Moving forward, a more longitudinal approach in training which incorporates aspects of critical care training early on during a cardiology fellowship would be best. A combined cardiology critical care fellowship wherein trainees rotate in various ICUs blends the best of both worlds. This gives the FIT early exposure throughout fellowship as opposed to just at the back end. Ultimately, regardless of how it is done, to be great at critical care cardiology you must be both a great cardiologist and intensivist.

There is a lack of tailored training programs for critical care cardiology. Do you think programs will evolve over the next couple of years or will it take much longer for critical care cardiology training to mature?

There is an overwhelming interest and enthusiasm in this burgeoning field. Programs have taken notice. I have seen a variety of different training models and there is room to grow in how we train future generations.

What advice do you have for FITs who are thinking of pursuing critical care cardiology?

1) Do not wait until your critical care medicine year to get exposure. Arrange for some additional ICU time, bronchoscopy and airway exposure throughout your training. Talk to your program leadership and see if you can tailor your training.

2) Leave your ego at the door. Keep an open mind and avoid “hard-wiring” your thinking. Once you delve in to the critical care medicine world, you will be exposed to different concepts and approaches. Incorporate this into your armamentarium to deliver the best care you can to your patients.

3) The field has become very popular among FITs over the last few years. If you are pursuing cardiac critical care, do it because you are passionate about it.

4) The unit is a special place and can be an emotional roller coaster – burnout is real. Take time for yourself and family. The key to longevity is a healthy balanced approach.

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