- Subspecialists in critical care cardiology (CCC) are in increasing demand, and due to the limited number of CCC fellowships, many CCC trainees are pursuing fellowships in critical care medicine (CCM)
- This paper proposes core elements for CCM curricula for CCC physicians-in-training and offers insights meant to help fellowship applicants critically evaluate the CCM programs they're considering
- Key competencies for CCC trainees are airway/ventilator management, management of mixed shock, direct management of mechanical circulatory support modalities, renal replacement therapy, neurologic emergencies, and post–cardiac surgery care
- Key issues for trainees to consider before selecting a program are the number and type of clinical rotations required and whether the training will prepare them to meet prospective employers' procedural and case quotas
Critical care cardiology (CCC) is a rapidly emerging subspecialty. Only a limited number of CCC fellowships are available, though, which has led many aspiring practitioners to complete a cardiology fellowship and then seek an additional year of training in a critical care medicine (CCM) fellowship.
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However, variations in practice between institutions and the absence of consensus training guidelines make it challenging to tailor a CCM curriculum for CCC.
David M. Dudzinski, MD, JD, director of the Cardiac Intensive Care Unit at the Corrigan Minehan Heart Center at Massachusetts General Hospital, and colleagues recently proposed how to design a contemporary training model for CCC through CCM fellowships. Their paper, published in the Journal of the American College of Cardiology, is also intended to help applicants for CCM fellowships critically evaluate the training goals and structure of the programs they're considering.
The Critical Care Cardiology Trials Network collects epidemiologic data about the leading indications for cardiac ICU (CICU) admissions and which indications are associated with the highest mortality, longest stays, and greatest resource utilization. Based on this data and current post-fellowship employment opportunities, the authors recommend prioritizing training in the following areas:
- Airway/ventilator management
- Management of mixed shock
- Direct management of mechanical circulatory support modalities
- Familiarity with renal replacement therapy
- Management of neurologic emergencies
- Caring for patients after cardiac surgery
The paper presents evidence-based data to support most of these goals. A figure in the article summarizes procedures and interventions trainees should master or become familiar with.
Caveats for Program Directors and Trainees
Clinical rotations—Eligibility guidelines for the American Board of Internal Medicine (ABIM) CCM board examination require four years of training consisting of 30 total months of clinical training time, of which 12 months must comprise critical care clinical training. Under ABIM Pathway A rules, trainees generally have critical care experience during their cardiology fellowship, so elective time tailored to CCC may be possible during their additional CCM year.
Yet CCM fellowship classes contain trainees with diverse training backgrounds and requirements. Because of institution-specific staffing needs, CCC trainees may be required to participate in clinical rotations beyond Accreditation Council for Graduate Medical Education (ACGME) requirements. This is an important issue to clarify before accepting a CCM fellowship.
Impending changes in Level III training requirements—The current Core Cardiology Training Statement (COCATS 4) of the American College of Cardiology (ACC) recommends eight weeks of direct cardiology critical care exposure with an additional 16 weeks of cardiovascular rotations to achieve level I proficiency in a broad range of critical care topics.
Additional critical care training is required to achieve level III proficiencies. Still, COCATS 4 recognizes only four proficiencies as level III: intra-aortic balloon pump placement, endotracheal intubation, design of safety/quality initiatives, and leading the CICU team.
However, the ACC plans to update the requirements for level III training in CCC. This is important for aspiring CCC trainees to know because COCATS requirements are not traditionally incorporated into CCM fellowship curricula.
Quotas—ACGME guidelines are silent about procedural and case quotas for CCM, but prospective employers may have credentialing quotas. Trainee proficiency is judged at the discretion of the fellowship program, resulting in inter-program variability. Trainees should inquire about credentialing quotas during interviews to ensure they'll obtain adequate exposure to be employable across diverse critical care settings.
The authors hope this paper will stimulate further development of standards and consensus by cardiologists and CICU physicians.
Learn more about Cardiac Surgery at Mass General
Refer a patient to the Corrigan Minehan Heart Center