I Am a Cardiologist
Walter Mashman, MD, FACC, Deputy Editor, JACC: Cardiovascular Interventions*
The field of cardiology is too important to be fragmented. While it is difficult for most people to believe that this might be possible, it is also important to recognize that there are real threats to the strength and respect that has been earned by generations of pioneer cardiologists.
Biological systems are capable of evolution and there are forces that drive this movement. Diversity is the critical component of a system that can allow it to survive an external threat. Sometimes the results of a migration can be roughly anticipated. Nonbiologic systems can operate under analogous principles. The field of cardiology is one such nonbiologic system that is subject to both internal and external pressures that will continue to drive its evolution. The field of cardiology is in constant evolution driven fundamentally by the high prevalence of cardiac problems and their impact on global health.
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The Threat
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Speciation.
There are several forces in place that could drive cardiology toward fragmentation leaving weak and vulnerable remnants. One such force is the blurring of the clinical boundary between cardiology and other fields. Certainly there are great things that can be accomplished by congenial collaboration with our colleagues, and there are many facets of cardiology that overlap with other fields. Hybrid interventional and surgical strategies bring some cardiologists more toward cardiac surgery and the cardiac surgeon more toward the role of traditional cardiologist. Similarly, we overlap and interface with vascular surgery, radiology, neuroradiology, nuclear medicine, and so forth. As these sub–sub-specialties of cardiology become refined, those physicians will tend to see themselves less and less as cardiologists. This speciation is analogous to that which has essentially removed cardiology from the field of internal medicine. As the new carotid arteriologists, for example, define new unique literature and training, they will be subjected to pressures that are different from mine. There will be a tendency for those highly skilled people to believe that their collective position is unique, and that they should move away from the parent field. It is easy to imagine how the blurring of the borders between cardiology and other fields could weaken the identity of the cardiologist and contribute to fragmentation.
Migration.
Another strong force that threatens fragmentation is the tendency toward isolation of the current subspecialties of cardiology. It is not difficult to imagine that in the future electrophysiologists will see themselves as distinct from cardiologists. Electrophysiology is a field in cardiology that requires unique skills and has a relatively isolated body of literature. In some institutions, electrophysiologists do not see the general cardiology patients and are not on-call with the general cardiologists. Subtly, even the name "electrophysiologist" excludes the label "cardiologist" and may subliminally undermine the attachment. There are some places where there are freestanding electrophysiology-only groups who behave as consultants to general cardiology groups. This separation of the field ironically comes from an area in cardiology that is still relatively young. Similarly, this departure from the parent field could be possible for interventional cardiology and for the imaging cardiologists. There are some places where groups of interventional cardiologists function only as laboratory-based consultants. In a future scenario, it is not hard to imagine that the nearly extinct general cardiologist would see the patients and consult an electrophysiologist, an interventional cardiologist, or a heart imaging physician when needed. If these areas were to splinter off from cardiology, it would weaken the parent field.
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Why Not Fragment?
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Cardiology has the most strength and clout because it should have the most strength and clout. The prevalence of cardiac problems and the resultant morbidity and mortality associated with those has led to resources to try to combat these problems. There is a lot of brain power, financial interest, and clinical care that is invested in improving heart problems because this is simply what is necessary on a national and global scale. If the strength and clout of cardiology is diluted by fragmentation, the combined strength of the remnant fields would be diminished. The sum of the parts is less than the whole.
If we become a collection of several loosely or historically related practices, then on the whole no harm is done in the short term. If, however, in the future a segment of the collective whole is threatened, isolationism will lead to weakness and potentially extinction. A grand example would be the discovery of a genetic manipulation, or the holy grail of cardiology: a drug that would systemically ensure plaque stability and regression. This would dramatically decrease the need for interventions...and for interventional cardiologists. Although that dramatic situation may not present itself in the course of most of our careers, more subtly this is highly likely to happen on a gradual basis. Because of its high stakes on a population scale, the practice of cardiology tends to evolve very quickly.
We have seen the Ferrari-like responsiveness in the practice patterns of electrophysiology through the 1990s to the present with a large surge in training, a big push to train defibrillator implanters, and now ebb with probably a surplus of electrophysiologists. The pendulum is probably shifting back in intervention as well. We saw the use of drug-eluting stents dampen after the early excitement and overall percutaneous coronary intervention volumes appear to be decreasing. While we do not yet know where the absolute future for growth is in the practice of cardiology, it might not come on the end of a catheter.
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Risk Tolerance and Survival
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The narrower an area becomes, the higher the stakes of the game. Just as a blue-chip stock involves less risk and has less reward, an initial public offering has higher risk but potentially pays off better. Diversity is the key to survival of any system, and the ability to tolerate risk will set the strategy for a field. The field of interventional cardiology is cued to tolerate high risk. This is a very strongly male-dominated field and men are prone to risk behavior (1). Although there have been monumental successes in interventional cardiology, there have also been tremendous—although less celebrated—failures. The more that interventional cardiology is integrated with general cardiology, the better it will be able to buffer its failures. If you play singles tennis and have a bad day, you will lose. If you play left field and have a bad day, your team may still win. The strength and foundation of the larger institution allows for more risk in smaller subspecialties, with a sharing or buffering of the collective outcomes. This diminishes the risk of high-risk behavior, allowing more risk to be relatively safely taken. Therefore, the successes can be bigger. As a large field, we will be better prepared to continue to lead in providing the best patient care, cross new frontiers in research and new therapies, and protect the lifestyles and incomes of our practioners.
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What Should We Do?
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Our specialty is—and should be—one of the largest and strongest of all of the medical specialties. Cardiology is a discipline that uniquely touches virtually every other field of medicine. We are a force that paves the way for other fields, allowing for improved care of all patients. The American College of Cardiology does not advocate only for the practice of cardiology, but for medicine in general.
How many fields is cardiology? Cardiac surgery, pediatric cardiology, intervention, peripheral intervention, heart failure, electrophysiology, valvuology, imager, lipidology, transplantology, atriology, preventology, cardiac researcher, cardiogeneology, and so on. The question is, how many fields do we want to be?
I propose we be one.
Although the new JACC journals could be misperceived as contributing to the chasm between the subspecialties of cardiology, it is important to know that the intent is to help unite the field by integrating the monumental intellectual reserve. I believe that this goal will be achieved. As interventional cardiologists become more specialized and tend to drift from the core of general cardiology, it is important that they continue to look to the College as the authoritative source of education, information, and advocacy. I think that the College understands that this is important and, working with the Society for Cardiac Angiography and Interventions, will continue to meet the needs of interventional cardiologists.
The American College of Cardiology is the institution that binds us together and brings us strength as cardiologists. This strength comes from the unity of support across subspecialties of cardiology. The College has earned clout in the political arena, and is the stalwart organization that brings us together.
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Footnotes
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Editor's note: In inviting Walter Mashman to be Deputy Editor of JACC: Cardiovascular Interventions I was looking not only for a bright, energetic, and committed cardiologist but also someone who could bring the perspective of comprehensive cardiology to our interventional world. Here, I ask him to speak to our readership about the value of a united cardiology community.
* Address correspondence to: Walter Mashman, MD, FACC, Piedmont Heart Institute, 275 Collier Road, Suite 300, Atlanta, Georgia 30309 (Email: walter.mashman{at}piedmont.org).
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REFERENCES
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- Baumeister RF. Is there anything good about men? 2007American Psychological Association, Invited Address, August 24; San Francisco, CA.
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The Threat
Why Not Fragment?