COMMENTARY

Why This Cardiologist Trained in Critical Care Medicine

An Interview With Erin Bohula

Interviewer: Michelle L. O'Donoghue, MD, MPH; Interviewee: Erin A. Bohula, MD, DPhil

Disclosures

October 15, 2019

This transcript has been edited for clarity.

Michelle L. O'Donoghue, MD, MPH: Hi. I'm Dr Michelle O'Donoghue, reporting for Medscape. Joining me today is my good friend and colleague, Dr Erin Bohula, who works at Brigham and Women's Hospital. She's a cardiologist in the cardiovascular division but she's also been ahead of the curve in terms of training in critical care medicine. Today we're going to be talking about this emerging field of critical care medicine and what it might mean for the future of trainees. Welcome, Erin.

Erin A. Bohula, MD, DPhil: Thanks so much for having me, Michelle.

Training in Critical Care Cardiology

O'Donoghue: As I mentioned, you moved ahead of the curve by making sure you were trained in critical care medicine as you pursued your training in cardiology. What brought you to that decision?

Bohula: From the start, I loved physiology, and that was part of the reason that I went into cardiology. In critical care medicine we obviously see that day in and day out. I loved that high-acuity realm with lots of physiology, so I wanted to focus on that. I elected to do cardiology training and supplemented that with specialized critical care training. Now I'm board certified in cardiovascular medicine and in critical care medicine. There is a fairly robust and emerging wave of people interested in specializing in critical care cardiology. Many of our trainees with similar interests are doing similar things.

O'Donoghue: Specializing in critical care has long been established within pulmonary medicine, but why do you think it's taken so long for it to be recognized as something that may require specialized training within cardiology?

Bohula: That is a great question and I think in part it's because of what the critical care unit (CCU) has been historically. In its inception, the CCU was used to taking care of people who were post–acute coronary syndrome (ACS), so in that realm, general cardiologists and interventional cardiologists would do it. There has been an evolution where more and more patients with heart failure have been in the intensive care units (ICUs) and the CCUs in general, so that brought in the advanced heart failure folks as attending in the CCU. There continues to be an evolution in the CCU where now we're seeing more and more medical issues, whether that is somebody who is purely overflow from the medical ICU or somebody with established cardiovascular disease who now has a superimposed medical problem and multiorgan system dysfunction.

The vast majority of our patients require mechanical ventilation or some level of high respiratory support, renal replacement therapy, or mechanical circulatory support. It's not just ACS anymore. It's broadly cardiology and then broadly medicine, too, which is why there is this push to say, "I want to feel comfortable with all aspects of critical care medicine, not just cardiology. I want to know what nutrition should look like and what pulmonary maneuvers I should be doing to take care of my patient who had a cardiac arrest and then ultimately acute respiratory distress syndrome with profound respiratory failure." We're dealing with a very complex patient population now, [and training offers] comfort in the facility with the more general medical stuff.

O'Donoghue: Mechanical circulatory support is an area that has been evolving so rapidly. It will be harder for people who trained years ago to catch up. It also raises that question as to whether or not cardiology itself should be expanding the field of critical care training under that umbrella, so that people like yourself who want to be in the CCU feel comfortable that they are adequately trained with all of these devices.

Bohula: Absolutely. Every institution is a little bit different on who manages patients who need mechanical circulatory support, and that may also be different by the mechanical circulatory support. It may be that somebody who has an Impella or TandemHeart is in the CCU while somebody who is on ECMO (extracorporeal membrane oxygenation) is within the cardiac surgical ICU. But nevertheless, all of those who are attending in the unit should be comfortable with these devices and also in thinking about the next step. What is the destination for this patient and what options do we have? They should be able to work very closely with the advanced heart failure team in terms of deciding whether this person is a candidate for durable therapies, transplant, or things like that. I agree 100% that mechanical circulatory support is a necessary component of focused training for somebody who is going to be in the CCU.

Advice for Trainees Interested in Critical Care

O'Donoghue: When trainees come to you and are trying to figure out their path forward, what do you advise them? What are their options right now?

Bohula: The field is evolving in many different ways and training is evolving. Many people in the field are pushing the idea that we should have specialized training. As of right now there is no specialized training program so there is no subspecialty that is critical care cardiology. There is not an ABIM board certification in that area. But you can train in cardiology and then train in critical care. That is what most people are doing and what I did.

There are different ways to do this, and every institution is figuring out what works for them and what they can develop within their own walls. I ultimately did the equivalent of a 1-year program in critical care under the umbrella of the pulmonary group and then was able to sit for their critical care medicine boards, and that was in addition to cardiovascular medicine. I've been telling trainees to work with their institutions and figure out how they can get the right requisites because there is no formalized pathway. You can do it as a totally separate thing. You could do cardiology and then go and do a specialized critical care medicine training which sometimes is 1-2 years. In Canada, I think it might even be 2 or 3 years. But there are very different models at the moment and no particularly formalized way of doing it.

O'Donoghue: We will see. I guess that might change in the future.

Bohula: I hope so.

Evidence Gap in the Critical Care Population

O'Donoghue: We're so lucky in cardiology that we have so many clinical trials, yet somehow with critical care medicine it has been slow to get patients randomized to different types of therapies and then figure out what really works. Where do you think that space is going right now?

Bohula: This is really a passion of mine. As you said, we are spoiled in cardiology. We have a huge evidence base to drive all of our guidelines, and we can be very comfortable in how we manage patients. But that is not the case in critical care cardiology. Virtually all of the randomized trials exclude the CCU population explicitly—patients with shock, for example—so we really don't have the evidence base. We extrapolate from the other trials, but that may not be fair because these patients are obviously different.

There is a movement and an interest across the critical care community of developing that evidence base. It is challenging because doing randomized trials in patients in shock, for example, and obtaining consent is challenging. It is hard to recruit for these trials but it's certainly possible, and it's been happening recently, such as with the CULPRIT-SHOCK and IABP-SHOCK II trials. I and some of my colleagues—Dave Morrow, Sean Van Diepen, and Jason Katz—developed the Critical Care Cardiology Trials Network, which is a North American network of about 25 centers where the goal is to do observational and randomized clinical studies in this space.

O'Donoghue: Which is huge. We can expect a lot of great things from this field moving forward. I'm sure it will continue to evolve over the next few years. Thank you so much for joining me today. Signing off for Medscape, this is Dr Michelle O'Donoghue.

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