Choosing a subspecialty: a moving target

Should one choose a job based on what is being done today or based on what one hopes will be done tomorrow?

One of the biggest assumptions in the medical training system is that amidst the daily rigor of clinical duties and patient care, a fellow will find his or her ultimate career destination along the way.

Unfortunately, a decision that has lifelong ramifications is often imposed on doctors in training at a very early stage. In residency, the decision to pursue a fellowship must be made shortly after completion of the universally exhausting intern year, as letters of recommendation and research interests must be targeted and aligned prior to the submission of an application.

How can the experience from one year be expected to alter one’s qualifications and shape a career path? As a fellow, the story is similar: One must decide whether or not to subspecialize and if so, must choose between electrophysiology, interventional cardiology, echocardiography, heart failure/transplantation, or noninvasive imaging.

Technology: changing subspecialties

Traditionally, a career path is guided by mentors, research interests and a personal propensity toward one disease entity or procedure. With technological advances, however, the practice of cardiology is likely to be very different 10 years from now. If a decision is based on the current state of affairs without envisioning the potential trajectory of the field, an individual might be stuck with something he or she didn’t sign up for.

Roderick Tung

When I sat down to interview for a cardiology fellowship at a New York City hospital two years ago, the program director said: “Heart transplantation as we know it will no longer exist in the next decade. We will be performing microtransplantation with stem cells.”

While I acknowledged the merit of his statement immediately, I found myself with little to say thereafter about my own research interests in heart failure. If medicine is constantly evolving, how can one be sure that his or her career decision is durable? How relevant are new technologies and changing practice patterns to choosing a career?

Technology alters careers

Technology inevitably changes careers. Since the advent of drug-eluting stents, the volume of bypass graft surgeries has drastically fallen across the nation, affecting the practice of cardiothoracic surgery. With data from ARTS II already presented, many are extrapolating the existing data from BARI, ARTS, and ERACI II, which demonstrate equivalence of bare-metal stents to CABG on mortality, to further support full revascularization achieved by drug-eluting stents.

While cardiothoracic surgeons have continually performed valve repair and replacement surgeries, the new EVEREST trial investigating percutaneous mitral valve repair by Alfieri stitch may further impinge on the status quo. Are interventional cardiologists the cardiothoracic surgeons of the future?

Carotid artery stenting was demonstrated to be noninferior to carotid endarterectomy in the SAPPHIRE trial, and trials involving renal artery stenosis and limb atherosclerosis are underway. Are interventionalists the vascular surgeons of tomorrow? While coronary interventions may be what primarily attracted them to the field, fellows pursuing careers in interventional cardiology may find themselves performing fewer coronary interventions and more percutaneous valves, closure of septal defects, and peripheral vascular interventions.

Within the past five years, the field of electrophysiology has shifted dramatically toward the arena of HF. Many electrophysiologists, first drawn to the field by radiofrequency ablation of arrhythmia, are now treating an entirely different population than what they had originally expected. Since the publication of the COMPANION trial, SCD-HeFT and, more recently, CARE-HF, the indications for ICDs and biventricular resynchronization pacing have rapidly expanded. These procedures have become the bread-and-butter for many practicing electrophysiologists.

Several training programs throughout the country have responded to this paradigm shift by creating combined electrophysiology/HF fellowships.

While pulmonary vein isolation for the treatment of AF is still in its infancy, many fellows may be turned off by the procedure due to the requirement of extensive mapping and deliberate circumferential ablation adding up to long procedural and fluoroscopy times. Will new technologies or approaches simplify this procedure?

Perhaps the electrophysiologists of the future will be performing ablations sitting outside of the procedure room using magnetic-guided stereotactic systems.

Imaging: changing the specialty

Lastly, the development of multidetector computed tomography (MDCT) for noninvasive coronary angiography has the potential to revolutionize the practice of internal medicine and cardiology. Preliminary studies demonstrate excellent sensitivity and specificity for identifying obstructive CAD when compared to the gold standard of angiography.

Currently, there are no recommendations for routine screening of CAD, although it remains the leading cause of death in the United States. The focus of primary prevention to date has only revolved around the treatment of identifiable risk factors.

Will MDCT emerge as the primary modality for screening of asymptomatic patients? Will MDCT be the study of choice for low- or intermediate-risk symptomatic patients? One may predict that the number of diagnostic catheterizations for the interventionalist will diminish in exchange for an increased number of interventions.

A young physician pursuing a career in nuclear cardiology must be prepared to integrate multiple imaging modalities including cardiac MR, EBCT, PET, in addition to MDCT, and assume the future role of “radiologist of the heart.”

These are only a few of the many examples illustrating how the technological imperative frequently changes job descriptions in medicine. In fact, numerous existing subspecialties were not even created and formalized until several years ago.

On the contrary, the promise of new innovations in a given field may never be realized if unfavorable data emerge. While advances are extremely exciting, it leaves many uncertain about what their job will actually be like after they sign up for it.

Should one choose a job based on what is being done today or based on what one hopes will be done tomorrow? While nobody can predict the future, the only thing for certain is change.

Roderick Tung, MD, a fellow at Cedars-Sinai, has joined the Cardiology Today Fellows Advisory Board in November 2005.