Author + information
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
- ↵∗Address for correspondence:
Dr. Jason Han, Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, Pennsylvania 19104.
Trainees entering the fields of cardiology and cardiovascular surgery in recent years are witnessing an era of constant change. In much the same way that the emergence of percutaneous coronary intervention offered new options for the treatment of coronary artery disease, new endovascular platforms are rapidly evolving as mainstays of the armamentarium available to address structural heart diseases (1,2). This dynamic transformation in the field’s trajectory compounds what is already an inherently challenging growth experience for trainees. In residency or fellowship, even the most rudimentary aspects of the job can be painstakingly rigorous and stressful. In addition to taking on new clinical responsibilities, most of the trainees’ waking moments are dedicated to honing new skills and acquiring new knowledge. In the face of this endovascular transformation, now it seems trainees also must learn to interpret and predict changes in the landscape of cardiology and cardiovascular surgery to set the “right” career course. In essence, we must undergo a transition within a transition. Facing this landscape, we aim to elaborate upon the current paradigm shift in cardiovascular surgery and to provide strategies on how trainees can effectively adapt to these changes.
When many of the current trainees started medical school 5 to 10 years ago, transcatheter aortic valve replacement was hardly included in the curriculum. However, in a remarkably short time span, this approach has been designated as a safe, effective, and patient-desired platform within the standard of care (3,4). The first PARTNER (Placement of AoRTic TraNscathetER Valve Trial) was published in 2010, including only the patients who were considered too high risk for conventional operations (5). Since then, both the outcomes and indications have evolved significantly (6,7). The PARTNER III trial by Mack et al. (7), which affirmed the safety and efficacy of transcatheter aortic valve replacement in low-risk patients, was published in the New England Journal of Medicine earlier this year. With each successive generation of device technology, studies report improved hemodynamic profiles, enhanced durability, and fewer adverse event rates (6,8,9). Similar endovascular trends are occurring in the treatment of mitral and tricuspid valve diseases and proximal aortic aneurysms. It seems that every week a new clinical trial on another innovative device arises, pushing the boundaries of what is widely accepted as standard within the field. Observing these changes, it is difficult to predict just how much and how quickly the treatment paradigm will progress over the next decade.
As trainees, being in this state of transition within a transition can be disorienting and anxiety-provoking, perhaps due to the fear of being wrong or left behind. We all share an intrinsic aversion to foreignness and uncertainty, having been raised in an educational system that rewards organization and early planning. A trainee’s perspective and ability to stay abreast of trends in the field are inherently limited by the virtue of being novices. It is akin to learning how to navigate across the sea for the first time as the positions of the stars are changing each day. We are confronted by uncertainties, such as how drastically the composition of practice that we see today may change by the time we finish training. Such questions are enough to give any contemporary trainee some trepidation.
However, while at first these challenges may seem unique to our present era, upon further reflection on the history of the field, we are reminded that constant evolution and innovation have always been the status quo. After all, training amid a dynamic current is an essential and inevitable experience of joining a highly innovative community. Trainees need not perceive of the paradigm shift as a disadvantage but rather see it as the cornerstone of progress and an opportunity to remain relevant. The term “paradigm shift” that Thomas Kuhn, an American physicist and philosopher, first coined in The Structure of Scientific Revolutions in 1962 (10), denotes a process by which a formerly and widely accepted worldview transitions to a new model in the face of emerging evidence. The rise of new paradigms fundamentally changes the ways in which society perceives or approaches a problem. Paradigm shifts have occurred across all disciplines, ranging from the emergence of heliocentrism and Newtonian laws in the field of physics to the Keynesian revolution in the field of economics. Although these transition periods are neither instantaneous nor without tension, and although they pose dynamic uncertainty about the future, they are markers of progress and forward motion that later serve as the pillar of future evolution.
The same is the case in cardiology and cardiovascular surgery, where the constant state of transition has long defined our innovative spirit. The emergence of the transcatheter valve replacement platform follows a plethora of previous paradigm shifts, including coronary artery bypass grafting, percutaneous coronary intervention, mechanical and bioprosthetic valves, generations of life-saving heart failure medicines, mechanical circulatory support, heart transplantation, and more (11,12). In fact, there has been no era in cardiovascular surgery and medicine that has been without disruptive innovation. In this context, the current shift toward endovascular interventions is neither unique nor final. Rapid innovation, not stasis, has always been and will continue to be the default of this profession.
Looking back on history, we can learn to not only take comfort, but also glean insights from how previous generations have dealt with impending paradigm shifts (Table 1). When drug-eluting stents first emerged, it was predicted to change the future of coronary artery disease treatments. Yet, Holmes et al. (11) astutely remarked that it is “only the most immediate and obvious example of a major paradigm shift” and that its successful incorporation will be a harbinger of how institutions assimilate other technologies in the future. In other words, one must learn to embrace unremitting transition, remaining adaptable as breakthroughs only beget more breakthroughs. In an essay describing a timeline of past paradigm shifts in heart failure, Sacks et al. (10) foreshadowed, “a timeline crafted three decades from now will reveal novel therapies and new paradigms that push our understanding … to a level unimaginable today.” In addition to adopting this mindset, it also involves being deliberate about learning and practicing a new skillset. As seen with paradigm shifts toward minimally invasive operations in other surgical fields, there is a formidable learning curve up front. Although this may discourage some of those who are already experts in former, already-established methods, it must be overcome with dogged persistence.
Another important strategy is to always acknowledge the limitations of our predictions. When embarking on a new chapter, such as residency or fellowship, it is tempting to project ahead and speculate what the future of the field will hold by the time we graduate. When we were interviewing for residency and fellowship positions, we were frequently asked what we envision as the trajectory or niche of our future careers. Many of us tried to assert foresight and confidence in our response. While doing so may feel productive, it may also lead to anchoring too rigidly to a strict framework or plan, which precludes fluidity as circumstances and technology change. If we were to commit early in residency to what we believe to be the future paradigm, then what will we do when we discover that it can change multiple times during the span of our training? We must be humble enough to pivot and to adapt.
Other practical solutions include engaging in social, and ideally, interdisciplinary forums that designate an opportunity to discuss and reflect on changes that are occurring. These relaxed opportunities might allow for introspection as well as acknowledgment among the group of trainees of ways they might be able to adjust within their shared experiences. Also, having diverse mentorship may help tailor the residents’ long-term goals in the context of an ever-changing field. It may even trigger further conversations regarding how to optimize one’s current training program or what additional training might be necessary to stay abreast of the newest trends. Last, residents should embrace opportunities within their training for continued education, including conferences and seminars focused on innovation.
Ultimately, if embraced, paradigm shifts can be advantageous. They bring together tremendous momentum and resources that would not exist during times of stasis. The emergence of transcatheter interventions for structural heart diseases and the heart team archetype have already led to meaningful benefits for trainees by providing a more diverse and enriched curriculum and promoting collaborations across disciplines. These changes have also helped broaden our perspectives. We have learned not only that paradigm shifts are natural, but also that they can be harnessed as opportunities to become future leaders in the field to help ambitiously shape its trajectory. Thus, let us remember as we seek our own paths as trainees during a time of transition, and as we toil to build our dreams upon ever-changing foundations, that pursuing medicine is a commitment to lifelong curiosity and learning. It is what makes our careers so fulfilling and rewarding. It is the true compass that guides us as we transition within a transition.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- Grover A.,
- Gorman K.,
- Dall T.M.,
- et al.
- Nappi F.,
- Spadaccio C.,
- Sablayrolles J.L.
- Grover F.L.,
- Vemulapalli S.,
- Carroll J.D.,
- et al.
- Mack M.J.,
- Leon M.B.,
- Thourani V.H.,
- et al.
- Kuhn T.
- Holmes D.R. Jr..,
- Firth B.G.,
- Wood D.L.