An interventional cardiologist: A cardiologist who intervenes☆☆☆

Article Outline

• Abstract
• References
• Copyright

Abstract 

Am Heart J 2002;143:943-4.

See related Editorials on pages 945 and 946.

As a medical student rotating through general surgery years ago, I heard the adage, “a good surgeon is an internist who operates.” In other words, a surgeon should know far more than technical skills. The well-trained surgeon should have adequate knowledge of general medicine and should bring that knowledge to bear when caring for the surgical patient.

A similar adage might be appropriate for the interventional cardiologist. A good interventional cardiologist should be a cardiologist first and foremost, and secondarily a cardiologist who performs percutaneous coronary interventions. The well-trained and properly credentialled interventional cardiologist should be comfortable with interpreting electrocardiograms and echocardiograms, treating congestive heart failure, or performing an electrical cardioversion. The interventional cardiologist should not forget to prescribe an angiotensin-converting enzyme inhibitor to patients with dilated cardiomyopathy or warfarin to patients with chronic atrial fibrillation. However, many interventional cardiologists, following some prominent national figures as role models, are becoming more focused on catheterization laboratory work alone.

If present trends are allowed to continue, interventional cardiologists will become more and more subspecialized. The subspecialized interventional cardiologists will view work outside their own narrow area of expertise as “scut-work,” to be delegated to noninterventional colleagues or physician-extenders. They will become increasingly uncomfortable and sloppy with noninterventional cardiology. I submit that this trend has already taken us past the point of diminishing returns in terms of quality and efficiency. In my view, there are 2 factors that are contributing to this trend: subspecialty interventional board examinations and minimum volume requirements.

Having just completed (and passed) the interventional board examination process, I was struck by the fact that the examination appeared to be in search of a curriculum that was substantial enough to justify a separate board examination. The examination seemed strangely out of balance with the reality of day-to-day interventional cardiology practice, and the preparatory review courses reflected this imbalance. It seemed to defy common sense to take review courses that were heavily dosed with topics such as mitral valvuloplasty or atrial septal defect closure devices—procedures that are used to treat uncommon problems and will probably never be performed by the majority of examinees. These topics are required to determine minimal competency? Wouldn't the time have been better spent reviewing broader cardiology issues?

The second issue, minimum volume requirements, has been controversial from the outset. The number of 75 procedures per year was forced on the cardiology community with the full knowledge that the average number of procedures per operator at the time was far lower. In a well-meaning effort to promote quality, the intent was to drive out the low-volume operators. The effort didn't work and the practicing cardiology community largely ignored the guidelines. The effort contributed to a rift that has widened between academic cardiologists and community cardiologists. The numbers also played to the advantage of established centers by limiting the ability of practitioners to start new programs and practices. Although minimum numbers for institutions have been shown to be important,¹ the value of minimal numbers for individuals remains arguable.² On average, higher-volume operators have better results, but restricting the practice of an individual cardiologist with a yearly volume below an arbitrary number is problematic.³ When patients choose an interventional cardiologist, volume should be one factor, but it would be unwise to reject a smart, experienced, and level-headed interventional cardiologist because of relatively low annual numbers. In fact, a high-volume operator might turn out to be a zealot with an unbalanced view of treatment options. The numbers game, nevertheless, is driving interventional cardiologists to work harder and harder to limit their practice to only interventional cardiology.

Interventional cardiology can be very satisfying and certainly has made a significant impact, but it comprises a small part of cardiology. In 1998, there were approximately 500,000 percutaneous coronary interventions performed in the United States. Yet, that same year, more than 6 million patients were discharged from hospitals with some type of cardiovascular disease.⁴ The effort to adequately care for all patients with cardiovascular disease far eclipses the effort involved in the catheterization laboratory. In my own practice group, an aggressive 12-member group with 10 interventionally trained cardiologists performing more than 1000 interventions per year, catheterization laboratory work accounts for <15% of our total workload (not billings, but actual time spent). The task of providing thoughtful, comprehensive care for all patients with cardiovascular disease is daunting and will require manpower. Yet the majority of trainees coming out of fellowship programs have unrealistic expectations regarding case volume and want to be full-time interventional cardiologists.

What do I suggest? Should we forget about credentialling and board examinations? Absolutely not. First, I would eliminate arbitrary minimum numbers in favor of a system of full disclosure. Let the public know the number of procedures each operator performs, and let patients choose their cardiologists on the basis of this information. Second, every hospital with an interventional program should be required to have a system for monitoring and evaluating risk-adjusted interventional outcomes. Each hospital should use outcome data internally as a direct measure of quality, rather than annual volume as a surrogate for quality. Finally, I suggest a restructuring of the cardiology board examinations. Perhaps the Continuous Professional Development initiative proposed by the American Board of Internal Medicine will be a move in this direction. I suggest that there be 3 types of cardiology boards: general cardiology boards (including echocardiography and cardiac catheterization), general cardiology boards with additional sections focused on intervention, and general cardiology boards with additional sections focused on electrophysiology. For initial credentialling, as well as for recertification, the interventional cardiologist should be expected to know the latest regarding pathophysiology, diagnosis, and treatment of all common cardiac conditions, in addition to the technical aspects of interventional cardiology. This would be a strong signal to the subspecialist that staying abreast of new developments in general cardiology is of the greatest importance. We should get back to the business of practicing cardiology in a balanced fashion. To achieve that goal, we should emphasize that a good interventional cardiologist should be a cardiologist who also intervenes.

Back to Article Outline

References 

1. Jollis JG, Peterson ED, EdLong ER, et al.  The relation between the volume of coronary angioplasty procedures at hospitals treating Medicare beneficiaries and short-term mortality. In: N Engl J Med. 331:1994;p. 1625–1629
   • View In Article
   • MEDLINE
   • CrossRef
2. Ellis SG, Weintraub W, Holmes D, et al.  Relation of operator volume and experience to procedural outcome of percutaneous coronary revascularization at hospitals with high interventional volumes. Circulation. 1997;95:2479–2484
   • View In Article
   • MEDLINE
3. Hannan EL. The relation between volume and outcome in health care. N Engl J Med. 1999;340:1677–1679
   • View In Article
   • MEDLINE
   • CrossRef
4. American Heart Association . 2001 Heart and Stroke Statistical Update. Dallas: : American Heart Association; 2000;
   • View In Article