Author + information
- Yogesh N.V. Reddy, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Yogesh N.V. Reddy, Division of Cardiovascular Diseases, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905.
As a fellow, beginning one’s training in cardiology represents a major life event. Having gone through seemingly countless years of training in medical school and, subsequently, in internal medicine, we were finally allowed to narrow our focus of study to something about which we were all passionate and excited. As a vast and complex branch of medicine, it is common early on in training for fellows to focus solely on mastering all of cardiology. Trying to keep up with all major advances in internal medicine is, understandably, not a major concern for the training cardiologist, particularly because we have devoted our career to providing expert care of the patient with complex cardiovascular disease.
The art of cardiology, however, often requires consideration of the patient as a whole. There are many clinical scenarios in which approaching patient care with an overly focused approach on a patient’s cardiovascular disease can lead to suboptimal outcomes and decision making. Because the life expectancy rate has continued to increase in the United States, most of our elderly patients now have myriad comorbidities that need careful consideration in our management decisions (1). As we take care of these increasingly complex patients, fully understanding the effects of noncardiac comorbidities and their contribution to symptomatology can help tremendously in the diagnosis of and therapy for cardiac problems. For example, the comprehensive evaluation of a patient with dyspnea requires a careful and thoughtful consideration of both cardiovascular and pulmonary etiologies, which can be achieved through an analytical approach to both cardiac and noncardiac investigations, such as chest computed tomography, pulmonary function testing, and arterial blood gas testing, among others. Most of this knowledge is based on training obtained during our residency in internal medicine, and if not continuously applied and updated, it can deteriorate over time.
One of the subspecialties of cardiology that requires extensive knowledge of a patient’s noncardiac issues is heart failure (2). One of my heart failure mentors, who is widely regarded as a master clinician, exemplified this for me during my residency. His excellence in clinical management was not merely due to a sound understanding of advanced heart failure and hemodynamics, but was also largely related to his thoughtful analysis and consideration of a patient’s other comorbidities. I began to realize that many heart failure hospitalizations can be prevented by careful management of a patient’s noncardiac comorbidities, including gout, chronic kidney disease, diabetes, and sleep apnea (3). In addition, most heart transplant physicians often become responsible for managing many of their patients’ other medical issues, especially given the complexity of drug interactions with immunosuppressive medications.
Perhaps the place where a broader knowledge of general medicine is most beneficial is in the cardiac intensive care unit (CICU). The CICU has evolved in the last 20 years from an observation unit after myocardial infarction to its present day iteration as a high-acuity unit managing complex cardiovascular patients susceptible to major systemic complications including renal failure, respiratory failure, ventilator-associated pneumonia, hepatic failure, thrombosis, and catheter-related infections (4). This is a rapidly evolving field that requires a broad medical knowledge base to deal with all of the issues that arise in these critically ill patients with multiorgan failure, advanced mechanical support, and immunosuppression after transplantation (5).
As fellows, in particular, we are often on the front lines when a patient arrives at the CICU with undifferentiated shock or respiratory failure. We all have seen cases in the CICU that were originally believed to be from cardiogenic shock but ultimately revealed themselves as septic shock. As the point of first contact, it is often up to us as fellows to quickly identify the noncardiac issues and implement a corrective plan. In patients with septic shock, rapid identification of the potential source and adequate initial antibiotic choice can make a huge difference in the ultimate mortality of an individual patient. Being able to rapidly diagnose and manage complicated acid base disturbances is a critical skill. Identification of diabetic ketoacidosis complicating cardiogenic shock or a myocardial infarction is often based on a slowly declining serum bicarbonate level and elevated anion gap, and if missed, can lead to severe acidosis and hyperkalemia. Identifying livedo reticularis in a patient with a recent coronary angiography and renal failure should raise suspicion for atheroembolic renal disease.
These are but a few examples of the tremendous amount of overlap between cardiology and other specialties. Awareness and knowledge of these issues can lead to more effective triage, diagnosis, and consultation for additional expertise, especially in our increasingly complex and elderly patients with multiple medical issues.
Strategies for Continuing Education in Internal Medicine as a Fellow
1. Develop a desire to learn aspects of medicine that are not immediately relevant to cardiology. Most of our complex patients require expert consultation from various specialties. Having a discussion with them about why they are recommending a certain test or management plan is a readily accessible teaching source. This can be an easy, time-efficient way of learning the most practical information about a particular noncardiac problem.
2. Follow 1 major medical journal, such as the New England Journal of Medicine or The Lancet, that can keep you updated on major breakthroughs in medicine that can affect our practice. Keeping up with all of the published studies in every branch of internal medicine is impractical and not relevant to the practicing cardiologist. Reviewing papers on critical care, nephrology and pulmonary medicine can serve as great “refreshers” on topics previously reviewed during early training, which remain clinically relevant to our practice, particularly in the CICU.
3. As an early career professional, take an active role in teaching residents and medical students. This is another great way to maintain one’s medical knowledge. Residents can often be a source of medical updates as well.
There is really no substitute for a thorough internal medicine education during initial medical training. Knowing that we were going into cardiology, many of us at some point in our residency felt that we could focus completely on cardiology. In my opinion, to become a good cardiologist, one needs to first and foremost be a good internist. With our increasingly complex patients, particularly those with advanced heart failure who present in the CICU, it is extremely important for cardiology fellows to remain well versed in internal medicine. This can have a profound effect on patient care, diagnosis, and treatment and can lead to rapid triage and appropriate expert consultation. I believe the fundamental principles we learned during our 3 years of internal medicine will continue to serve us well as we progress in our careers as cardiologists. With a refocused effort, we can all hone the valuable skills we learned in internal medicine and continue to grow as well-rounded cardiologists, ultimately to the benefit of our patients.
- Gary S. Francis, MD ()
RESPONSE: You Are Always a Doctor First!
I was delighted to see Dr. Reddy’s piece on the importance on not giving up on the practice of internal medicine. Virtually all cardiologists in the United States have gone through an internal medicine training program, and the vast majority of them are certified in internal medicine. Although all of us have chosen the pathway of cardiovascular medicine as our passion, it is naive to think that we do not use our internal medicine background. When I first began to evaluate and manage patients following heart transplantation, it became clear that I needed to understand infectious disease, immunology, and nephrology to appropriately care for these patients. The patients had cytomegalic viral infections, fungal infections, and adverse effects from prednisone. Bone marrow immunosuppression and delayed wound healing were not uncommon. Thus, one has to practice internal medicine.
The myriad of comorbid conditions that occur in patients with heart failure is also substantial, as pointed out by Dr. Reddy. Cardiologists who care for patients with advanced heart failure must be up to date about diabetes mellitus, kidney function impairment, and many other common internal medicine problems. Even though many of us practice at large academic medical centers, it simply is not practical to call on consultants for straightforward noncardiovascular problems. For many years, I was director of a very large cardiac intensive care unit (CICU) at the Cleveland Clinic, which afforded me an opportunity to learn a great deal of internal medicine. There is something about working regularly in a busy CICU that keeps you up to date and provides a wealth of material to pique your curiosity regarding noncardiac conditions.
I agree wholeheartedly with Dr. Reddy that a good cardiologist should have a strategy for continuing his or her education in internal medicine. This begins during the fellowship training and should become a lifelong journey. Cardiology trainees should be encouraged to read The Lancet, the Annals of Internal Medicine, the New England Journal of Medicine, and JAMA. The clinical pathology cases that are published weekly in the New England Journal of Medicine continue to be a rich source of internal medicine materials. Attendance at medicine grand rounds is useful, and interaction with junior colleagues regarding internal medicine problems can be most enlightening.
So, Dr. Reddy is spot-on. We are all doctors first and internal medicine specialists second, and our passion typically lies within some area of cardiovascular medicine. These 3 entities are intertwined to a large extent and should remain a triumvirate not to be unbound.
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