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- Spencer B. King III, MD, Editor-in-Chief, JACC: Cardiovascular Interventions⁎ ()
- ↵⁎Address for correspondence to:
Spencer B. King III, MD, Editor-in-Chief, JACC: Cardiovascular Interventions, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road, NE, Atlanta, Georgia 30342
In this era of dramatic advances in interventional cardiology with the phenomenal progress in treating structural heart disease, improving systems of ST-segment elevation myocardial infarction (STEMI) care and expanding peripheral vascular interventions, one would think that our subspecialty would be the most popular one to which medical students would aspire. Without any scientific evidence I am beginning to wonder if this is the case.
Recently, I had the chance to review data from about one-half of the interventional cardiology programs in the U.S. Among the questions asked of the incoming fellows was the medical school they attended. The answers surprised me as a significant percentage were foreign medical graduates, and U.S. medical student graduates comprised only about 60% of those entering interventional cardiology training. This data did not surprise me because of any pre-conceived notion that the foreign medical graduates were not superb candidates for training in interventional cardiology, as most of them are. What surprised me was that there is a dearth of graduates of U.S. medical schools entering the field. It is well known that applications to cardiac surgery programs are in a severe lull and much of that is due to the ascendency of interventional cardiology. Is interventional cardiology now following the course of cardiac surgery? What could be the explanation for the dominance of foreign medical graduates? It could be that foreign graduates entering residency training in the U.S. are simply better. They are frequently at the head of their medical school class and may have greater motivation (the immigrant factor). I do not discount this but there could be a waning of enthusiasm for interventional cardiology among U.S. medical students.
The career in interventional cardiology originally populated by a bunch of cardiologists who were probably “frustrated surgeons” was incredibly challenging and interesting. To accomplish difficult things is thrilling. As techniques and equipment have improved, results have become more predictable. Nonetheless, interventional cardiology practiced at a high level remains challenging but it is definitely not a lifestyle specialty. The growth in applications for residencies in those specialties—radiology, anesthesiology, ophthalmology, dermatology, or plastic surgery—may speak to a desire for a life beyond medicine, not an unreasonable goal. (A case in point—I am returning from participating in the William Harvey Trophy golf competition. This reasonably high-handicap contest between a group of cardiologists from the U.S., Great Britain, Ireland, and continental Europe bring them together every 2 years for a week of non-continuing medical education activity. For the record, the contest in San Francisco ended with the U.S. claiming the trophy for the first time in 3 years [Fig. 1].)
Women are now the majority in medical schools in the U.S., and we have not been very successful in attracting them into a field with potential radiation hazards and family-unfriendly call schedules. Another possible reason for muted interest in interventional cardiology is that we may have been too enthusiastic promoting the field in the past. Whereas there may be communities needing additional interventional cardiologists, there are not so easy to find. I recently had conversations with colleagues from England, Ireland, France, and Austria. The interest in interventional cardiology remains high in those countries but the employment opportunities are limited ensuring high-volume activity once employed. In Vienna, for example, the operators performing primary percutaneous coronary intervention for STEMI must be the most experienced with an annual volume of total cases more than 2 times the minimum requirement in the U.S. Perhaps our students do not see training in interventional cardiology leading to full-time cutting-edge practice of the specialty, but rather an added skill that compliments their general cardiology practice. Then, there are economic conditions, which cause significant angst among the seriously indebted U.S. medical student. Finally, one wonders what effect the press coverage of studies such as COURAGE and BARI 2D have had on medical student psychology. The success of medical therapy in preventing events among patients with stable ischemic heart disease will make the appropriate selection for adding interventional procedures critical. On the other hand, the expanding indications (think left main disease) and hybrid collaborations with surgical colleagues will expand the indications.
Things move in cycles and interest in medical specialties is no exception. Whether greater numbers of interventional cardiologists are needed or not, the need for highly experienced and innovative operators will only expand as cardiovascular medicine continues to become less invasive. Hopefully the best and brightest American medical school graduates will join the best and brightest foreign graduates to continue to ensure the future of our specialty.