The In and the Out
Interventional cardiology is a unique medical discipline with a knowledge base of internal medicine and cardiology coupled with physical skill and analytic thinking common to surgical subspecialties. Not surprising, the training required to become an interventional cardiologist is substantial and ending one’s career as an interventionalist presents special challenges. Given the focus and physical demands required to excel at this discipline, retirement may come early in one’s professional career. Unfortunately, there are no guidelines of when to stop being an interventionalist or what pursuits should follow. In the article, we will discuss the issues most pertinent to the initiation and completion of a career as an interventional cardiologist.
The first challenge in the pursuit of a career as an interventional cardiologist comes during training. In its earliest days, interventions performed in cardiac catheterization laboratory were limited to percutaneous transluminal coronary angioplasty and there was no formal curriculum for trainees.1 Now 40 years later, the coronary interventional cardiologist’s toolbox is vast and includes multiple complex and specialized therapies including stenting, atherectomy, hemodynamic support devices, filters, and thrombectomy. Furthermore, the techniques and strategies for advanced and high-risk interventions have increased in complexity and require more dedicated educational time to master.
The scope of practice of interventional cardiology is no longer limited to coronary interventions, but rather has expanded to include peripheral vascular and structural interventions. Moreover, the magnitude and complexity of this menu of tasks is so substantial that many say that no single individual interventionalist can master all of them.
To effectively educate trainees in all facets of coronary interventions, while also incorporating training in peripheral vascular and structural interventions, many training programs have expanded from 1 to 2 or 3 years in duration.2 The average trainee will already have spent 6 years completing internal medicine residency and general cardiology fellowship. The approximately 8 years of postgraduate training, the majority of which are spent outside of the cardiac catheterization laboratory, is similar to the most advanced surgical subspecialties. Prospective interventional cardiologists must consider the personal and financial impact of this long training period. Additional considerations, including declining procedural volume, debt accumulation during training, and a changing healthcare landscape, make the current journey to becoming an interventional cardiologist distinctively challenging.
Once training is complete, newly minted interventionalists become acquainted with an evolving job landscape. Interventional cardiologists continue to generally be in demand nationally, and there are multiple areas around the country with a significant need for more operators. However, the types and locations of available jobs may present challenges for some. Many young interventionalists will find limited job availability and lower compensation in large cities and highly desired parts of the country, and many jobs come with an increasing percentage of time spent within noninvasive cardiology.3 Furthermore, it is difficult to find job opportunities that use all of the procedural skills one acquires during training. As such, after many years of rigorous training with a focus on mastering multiple tools and techniques, graduating interventional cardiologists may need to make significant compromises with respect to which skills and procedures they are willing to forgo after training.
Young interventional cardiologists face multiple challenges early in their career. Many of these are common to all physicians, including developing relationships with effective mentors, securing adequate funding for research or protected time, and paying off debt.4 More unique to the field of interventional cardiology is the early and proactive management of the occupational hazards of the field, including radiation safety and orthopedic injuries. Young interventional cardiologists must take these issues seriously and be wary to not hasten their careers. Radiation exposure has serious negative long-term effects, and physicians are wise to educate themselves on the risks of exposure and master radiation safety techniques that can mitigate these risks. Certain practices, such as minimizing fluoroscopy time, using dose reduction technologies, using protective shielding and clothing, and understanding radiation scatter and which positions and views place one at highest risk for exposure, can have a significant impact on one’s effective radiation exposure and long-term risks.5
Although the potential long-term risks of radiation exposure may seem most alarming to young interventional cardiologists, orthopedic injuries are the most likely hazard to impact their ability to work.6 Years of long hours on one’s feet wearing heavy protective gear can lead to significant musculoskeletal injuries, and it is essential that young interventionalists prioritize care of their own bodies and health and reduce procedural time if and when it is medically necessary.
A career as an interventional cardiologist will likely involve many more challenges, such as dealing emotionally and professionally with procedural complications and negative outcomes, managing malpractice issues, preventing burnout, and maintaining a healthy work and life balance. These challenges will hopefully be far outpaced by the numerous positive aspects of the field, such as the intellectually and physically stimulating day-to-day work and the enormous impact on patients.
In this fairly young specialty, many interventional cardiologists, currently at the end of their careers, were present for the birth of the field. As with many medical specialties, practicing for so long within one field, especially one as demanding, dynamic, and impactful, as interventional cardiology, can leave a significant footprint on one’s identity, making it difficult to walk away. One of the most difficult decisions is choosing when exactly to stop practicing, which requires careful consideration of one’s proficiency, mental and physical stamina, and desire to continue to practice.
Even as the image of retirement has a connotation of relaxation and free time, there are aspects of retirement that can be problematic. Some of these concerns are common to all areas of the medical profession and include a sense of loss in terms of being a healthcare provider for others. Moreover, interventional cardiologists have unique experiences different from even other cardiologists. One, for example, is the role of the interventionalist in the treatment of patients with acute myocardial infarction. Primary percutaneous coronary intervention can be lifesaving yet it is physically and intellectually demanding given the acuity and severity of the illness, the need for critical decisions, and the unpredictability of when patients present. In spite of these demands, the sense of a job well done that the interventionalist feels after a successful primary percutaneous coronary intervention is special. This ability to provide immediate and substantial clinical improvement is difficult to find in other areas of cardiovascular medicine.
Although the senior interventionalist has the advantage of experience, the proficient operator must adapt to new techniques, devices, and procedural approaches. Although technological advances may lead to improved approaches that benefit patients, it can be difficult to alter one’s practice after decades of mastering an alternative approach. The advent of radial access is a particularly excellent example, with a new approach that is clearly beneficial to patients, but requires a commitment to and mastering of a new set of skills and routines. As we have seen with the slow adoption of radial access in the United States, sometimes the biggest challenge is overcoming inertia.7 Interventional cardiology is not a static field, and one must remain open to acquiring new skills throughout a career.
What options are available to the physician who stops performing cardiac interventions? One may retire and no longer function as a physician. Alternatively, there are noninterventional cardiovascular career opportunities such as administration, teaching and investigation, functioning as a noninvasive cardiologist, or a combination of these options.8
Some have expressed concern about aging physicians and have called for formal physical and cognitive testing. Certainly age as a criterion for termination of work is arbitrary and does not recognize the variability of individual capability. Nevertheless, some institutions have been active in addressing these concerns. Both the University of Pittsburgh and Cooper University Healthcare, for example, require physical examinations and cognitive testing for physicians over age 70 years. Penn Medicine requires routine cognitive testing.9 More detailed is a 2-day evaluation of performance for aging surgeons at the Sinai Hospital in Baltimore. The program includes a general physical examination, hearing screening, a neurological examination, a neuropsychology evaluation, and a formal ophthalmologic examination.10
There seems to be no single strategy for exiting the field of interventional cardiology. Yet there is concern by hospitals, healthcare systems, medical schools, and certainly by physicians. This topic is worthy of study, and hopefully efforts are in place to identify scientifically based guidelines that will permit informed decisions.
Interventional cardiology is one of the most demanding and rewarding medical specialties. There are unique challenges to both launching and completing a career as an interventionalist that deserve consideration. Physicians should embrace and address these challenges with appreciation for the many positive aspects of this extremely satisfying and rewarding career.
The opinions expressed in this article are not necessarily those of the American Heart Association.
- © 2018 American Heart Association, Inc.
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- 10.↵The Aging Surgeon Program Protocol. 2018. http://www.agingsurgeonprogram.com/AgingSurgeon/AgingSurgeon.aspx. Accessed March 2, 2018.