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In the second part of a discussion of the potential integration of Cardiac Surgery and Interventional Cardiology, two "early adopters" - Mathew Williams at New York Presbyterian Hospital-Columbia and Michael Davidson at the Brigham and Women's Hospital - continue their personal perspective on potential problems and training challenges such integration might entail.
Dr. Davidson notes there are some downsides to this new type of practice. “The issues that all of us face that do this - the 'ugly underbelly,' if you will - revolve around competition and turf. It plays out differently in every institution due to differences in reimbursement at each institution, etc.
"But even if reimbursement is not the issue, there are also issues of identity. There is a little element of being in 'no man's land': you are set aside from your cardiac surgery colleagues because you do things that they don't. And on the flipside you have the cardiologists, who are largely supportive, but there is always a little worry about encroachment on turf that you have to be very careful about. I don't think anyone has the ideal solution to this."
Looking to the future and the idea of the integration of cardiac surgery and interventional cardiology, both focused on potential changes in training programs. As a first point, they both noted that a significant amount time is required to master catheter-based skills."We need to accept that it takes more than three months to learn," Dr. Williams said.
Dr. Davidson echoed and expanded on this point: "One of the dangers cardiac surgeons face is that because they have such a high degree of technical skills, they tend to not have enough appreciation for the degree of technical skill that is involved in being a good, competent interventional cardiologists. Sometimes, cardiac surgeons assume that because they have good surgical skills, they can waltz into a cardiac catheterization lab and 'figure it out' in a short period of time and this is simply not true. One actually needs to put in a fair amount of time and do a few hundred cases to gain advanced catheter skills.
"One can get lulled into a sense of ease by doing a couple of easy procedures (e.g. a straightforward aortic stent graft) and then getting a sense that endovascular work is very easy. But in fact when one does more advanced procedures, one sees that it actually does take a lot of technical skill. For a cardiac surgeon to do this right, they have to understand the idea that you can't do a weekend or month-long course and expect to have real endovascular competency. "
"There's a bit of a paradox in that many feel it would be good to have more of a cardiac surgical presence in the cath lab; at the same time you risk having cardiac surgeons who are inadequately trained and may get into trouble assuming their surgical skills translate into endovascular skills."
Both went on to comment on the changes in training that would be necessary if interventional cardiology and cardiac surgery were to merge in the future. "There's a lot of divergence of opinion here. I am in the camp that believes that the separation of interventional cardiology and cardiac surgery is artificial and based on historical models that may not apply anymore. I think we should go more towards disease based treatment but in doing this, there would be a blurring of the lines as to be who should be doing what. One way to avoid the 'turf battles' and to achieve better integration would be to have the training integrated from the beginning," said Dr. Davidson.
"One of the problems that has been brought up is in this country is that often the treatment a patient gets is determined by who they happen to go see - one treatment if they go to a surgeon and one treatment if they go to a cardiologist" for the same disease.
"Ideally, if you train people from the ground up to be disease managers and then further differentiate from that point,"say 'outpatient clinicians' versus 'imaging clinicians' versus those that do 'big procedures' or endovascular procedures but united by their core training, it may reduce the 'turf battles' that are actually not very good for patients. The core should be patient care", Davidson continued.
In making any large-scale change, there are always two options: swift, radical action or more gradual stepwise changes.
"The question becomes should we do this by mass upheaval or incremental steps over time? Hard to know," Dr. Davidson remarked.
There are multiple complexities involved in such a change, he noted: "there are a lot of realities that go into this. For instance, the idea of merging cardiology and cardiac surgery doesn't take into account some practitioners who want to divide their time between cardiac and thoracic surgery. This group is more committed to keeping cardiac and thoracic surgery together and maintaining the general surgery training. So, there is an internal conflict/struggles even within CT surgery; in addition to the potential conflicts between cardiac surgery and cardiology."
On his vision of the future, Dr. Williams commented, "going forward, what I imagine is continued slow evolution - that's not my dream; I would hope for merged departments."
He went on to express concern regarding the future of cardiac surgery training. "Cardiac surgery is moving too slowly, in my opinion. At our institution, for example, we've been starting a six-year training program but given the amount of thoracic and general surgery they are required to do, we are not going to be training the cardiac surgeon of the future. Unless we radically change the training structure, true integration of the fields is never going to happen."
Dr. Williams pointed out that in his experience, the primary force of resistance to the idea of the integration of interventional cardiology and cardiac surgery was not from the medical side: "Actually in my experience, the cardiologists have embraced this a lot more than cardiac surgery.
"The resistance is not so much from the medical side as the surgical side. They have been a lot more receptive to this. Cardiothoracic surgeons seem to be more interested in fighting about turf instead of really looking at what the appropriate training is."
In the second part of a discussion of the potential integration of Cardiac Surgery and Interventional Cardiology, two "early adopters" - Mathew Williams at New York Presbyterian Hospital-Columbia and Michael Davidson at the Brigham and Women's Hospital - continue their personal perspective on potential problems and training challenges such integration might entail.
Dr. Davidson notes there are some downsides to this new type of practice. “The issues that all of us face that do this - the 'ugly underbelly,' if you will - revolve around competition and turf. It plays out differently in every institution due to differences in reimbursement at each institution, etc.
"But even if reimbursement is not the issue, there are also issues of identity. There is a little element of being in 'no man's land': you are set aside from your cardiac surgery colleagues because you do things that they don't. And on the flipside you have the cardiologists, who are largely supportive, but there is always a little worry about encroachment on turf that you have to be very careful about. I don't think anyone has the ideal solution to this."
Looking to the future and the idea of the integration of cardiac surgery and interventional cardiology, both focused on potential changes in training programs. As a first point, they both noted that a significant amount time is required to master catheter-based skills."We need to accept that it takes more than three months to learn," Dr. Williams said.
Dr. Davidson echoed and expanded on this point: "One of the dangers cardiac surgeons face is that because they have such a high degree of technical skills, they tend to not have enough appreciation for the degree of technical skill that is involved in being a good, competent interventional cardiologists. Sometimes, cardiac surgeons assume that because they have good surgical skills, they can waltz into a cardiac catheterization lab and 'figure it out' in a short period of time and this is simply not true. One actually needs to put in a fair amount of time and do a few hundred cases to gain advanced catheter skills.
"One can get lulled into a sense of ease by doing a couple of easy procedures (e.g. a straightforward aortic stent graft) and then getting a sense that endovascular work is very easy. But in fact when one does more advanced procedures, one sees that it actually does take a lot of technical skill. For a cardiac surgeon to do this right, they have to understand the idea that you can't do a weekend or month-long course and expect to have real endovascular competency. "
"There's a bit of a paradox in that many feel it would be good to have more of a cardiac surgical presence in the cath lab; at the same time you risk having cardiac surgeons who are inadequately trained and may get into trouble assuming their surgical skills translate into endovascular skills."
Both went on to comment on the changes in training that would be necessary if interventional cardiology and cardiac surgery were to merge in the future. "There's a lot of divergence of opinion here. I am in the camp that believes that the separation of interventional cardiology and cardiac surgery is artificial and based on historical models that may not apply anymore. I think we should go more towards disease based treatment but in doing this, there would be a blurring of the lines as to be who should be doing what. One way to avoid the 'turf battles' and to achieve better integration would be to have the training integrated from the beginning," said Dr. Davidson.
"One of the problems that has been brought up is in this country is that often the treatment a patient gets is determined by who they happen to go see - one treatment if they go to a surgeon and one treatment if they go to a cardiologist" for the same disease.
"Ideally, if you train people from the ground up to be disease managers and then further differentiate from that point,"say 'outpatient clinicians' versus 'imaging clinicians' versus those that do 'big procedures' or endovascular procedures but united by their core training, it may reduce the 'turf battles' that are actually not very good for patients. The core should be patient care", Davidson continued.
In making any large-scale change, there are always two options: swift, radical action or more gradual stepwise changes.
"The question becomes should we do this by mass upheaval or incremental steps over time? Hard to know," Dr. Davidson remarked.
There are multiple complexities involved in such a change, he noted: "there are a lot of realities that go into this. For instance, the idea of merging cardiology and cardiac surgery doesn't take into account some practitioners who want to divide their time between cardiac and thoracic surgery. This group is more committed to keeping cardiac and thoracic surgery together and maintaining the general surgery training. So, there is an internal conflict/struggles even within CT surgery; in addition to the potential conflicts between cardiac surgery and cardiology."
On his vision of the future, Dr. Williams commented, "going forward, what I imagine is continued slow evolution - that's not my dream; I would hope for merged departments."
He went on to express concern regarding the future of cardiac surgery training. "Cardiac surgery is moving too slowly, in my opinion. At our institution, for example, we've been starting a six-year training program but given the amount of thoracic and general surgery they are required to do, we are not going to be training the cardiac surgeon of the future. Unless we radically change the training structure, true integration of the fields is never going to happen."
Dr. Williams pointed out that in his experience, the primary force of resistance to the idea of the integration of interventional cardiology and cardiac surgery was not from the medical side: "Actually in my experience, the cardiologists have embraced this a lot more than cardiac surgery.
"The resistance is not so much from the medical side as the surgical side. They have been a lot more receptive to this. Cardiothoracic surgeons seem to be more interested in fighting about turf instead of really looking at what the appropriate training is."
In the second part of a discussion of the potential integration of Cardiac Surgery and Interventional Cardiology, two "early adopters" - Mathew Williams at New York Presbyterian Hospital-Columbia and Michael Davidson at the Brigham and Women's Hospital - continue their personal perspective on potential problems and training challenges such integration might entail.
Dr. Davidson notes there are some downsides to this new type of practice. “The issues that all of us face that do this - the 'ugly underbelly,' if you will - revolve around competition and turf. It plays out differently in every institution due to differences in reimbursement at each institution, etc.
"But even if reimbursement is not the issue, there are also issues of identity. There is a little element of being in 'no man's land': you are set aside from your cardiac surgery colleagues because you do things that they don't. And on the flipside you have the cardiologists, who are largely supportive, but there is always a little worry about encroachment on turf that you have to be very careful about. I don't think anyone has the ideal solution to this."
Looking to the future and the idea of the integration of cardiac surgery and interventional cardiology, both focused on potential changes in training programs. As a first point, they both noted that a significant amount time is required to master catheter-based skills."We need to accept that it takes more than three months to learn," Dr. Williams said.
Dr. Davidson echoed and expanded on this point: "One of the dangers cardiac surgeons face is that because they have such a high degree of technical skills, they tend to not have enough appreciation for the degree of technical skill that is involved in being a good, competent interventional cardiologists. Sometimes, cardiac surgeons assume that because they have good surgical skills, they can waltz into a cardiac catheterization lab and 'figure it out' in a short period of time and this is simply not true. One actually needs to put in a fair amount of time and do a few hundred cases to gain advanced catheter skills.
"One can get lulled into a sense of ease by doing a couple of easy procedures (e.g. a straightforward aortic stent graft) and then getting a sense that endovascular work is very easy. But in fact when one does more advanced procedures, one sees that it actually does take a lot of technical skill. For a cardiac surgeon to do this right, they have to understand the idea that you can't do a weekend or month-long course and expect to have real endovascular competency. "
"There's a bit of a paradox in that many feel it would be good to have more of a cardiac surgical presence in the cath lab; at the same time you risk having cardiac surgeons who are inadequately trained and may get into trouble assuming their surgical skills translate into endovascular skills."
Both went on to comment on the changes in training that would be necessary if interventional cardiology and cardiac surgery were to merge in the future. "There's a lot of divergence of opinion here. I am in the camp that believes that the separation of interventional cardiology and cardiac surgery is artificial and based on historical models that may not apply anymore. I think we should go more towards disease based treatment but in doing this, there would be a blurring of the lines as to be who should be doing what. One way to avoid the 'turf battles' and to achieve better integration would be to have the training integrated from the beginning," said Dr. Davidson.
"One of the problems that has been brought up is in this country is that often the treatment a patient gets is determined by who they happen to go see - one treatment if they go to a surgeon and one treatment if they go to a cardiologist" for the same disease.
"Ideally, if you train people from the ground up to be disease managers and then further differentiate from that point,"say 'outpatient clinicians' versus 'imaging clinicians' versus those that do 'big procedures' or endovascular procedures but united by their core training, it may reduce the 'turf battles' that are actually not very good for patients. The core should be patient care", Davidson continued.
In making any large-scale change, there are always two options: swift, radical action or more gradual stepwise changes.
"The question becomes should we do this by mass upheaval or incremental steps over time? Hard to know," Dr. Davidson remarked.
There are multiple complexities involved in such a change, he noted: "there are a lot of realities that go into this. For instance, the idea of merging cardiology and cardiac surgery doesn't take into account some practitioners who want to divide their time between cardiac and thoracic surgery. This group is more committed to keeping cardiac and thoracic surgery together and maintaining the general surgery training. So, there is an internal conflict/struggles even within CT surgery; in addition to the potential conflicts between cardiac surgery and cardiology."
On his vision of the future, Dr. Williams commented, "going forward, what I imagine is continued slow evolution - that's not my dream; I would hope for merged departments."
He went on to express concern regarding the future of cardiac surgery training. "Cardiac surgery is moving too slowly, in my opinion. At our institution, for example, we've been starting a six-year training program but given the amount of thoracic and general surgery they are required to do, we are not going to be training the cardiac surgeon of the future. Unless we radically change the training structure, true integration of the fields is never going to happen."
Dr. Williams pointed out that in his experience, the primary force of resistance to the idea of the integration of interventional cardiology and cardiac surgery was not from the medical side: "Actually in my experience, the cardiologists have embraced this a lot more than cardiac surgery.
"The resistance is not so much from the medical side as the surgical side. They have been a lot more receptive to this. Cardiothoracic surgeons seem to be more interested in fighting about turf instead of really looking at what the appropriate training is."