AHA FIT Newsletter

1. Congratulations on your extremely rewarding career and leadership in the field of Critical Care Cardiology! Can you describe your journey in clinical cardiology and academic medicine?

Thank you so much for the opportunity to chat today. It most certainly has been an enjoyable and rewarding career thus far. My pathway to this point has been anything but straightforward. I entered medical school with an interest in becoming a pediatrician. However, it took me less than a weCOnek in a community practice, early in my medical training, to recognize that I had neither the requisite skill nor the demeanor to take care of sick children. I very much enjoyed most of my clinical rotations during medical school, and ultimately settled on a career in Emergency Medicine (EM). I matched in the University of Texas-Southwestern (UTSW) EM program and began my internship there.

I definitely enjoyed EM training. I loved the procedures, the acuity, the pace…but what I didn’t enjoy as much was the lack of continuity. When my other colleagues would leave their shift, head home, and prepare for a new set of challenges on a new day, I instead felt compelled to visit the ICUs to see what had happened to the patients I had triaged earlier in my shift. It bothered me that I couldn’t take care of patients through their entire acute illness. A little over halfway through my internship, I was called by the longtime Internal Medicine (IM) program director at UTSW, Dr. David Hillis. I’ll never forget what he said – “Jason, I hear you are doing the wrong thing. You’re supposed to be an Internist.” He offered me a preliminary spot as an intern in the IM program for the coming academic year; although there was no guarantee, he assured me that the chances were good that a categorical spot would eventually open up. After much deliberation, I accepted his offer. I finished out my EM intern year and then immediately began as an intern in the IM program. While the idea of doing 2 internships might sound horrible to others, it was actually a great experience. I truly believe that one spends a large chunk of their intern year just learning to become an intern. For my second internship, however, I didn’t have to do that – instead, it was just about soaking up knowledge. I also would argue that I wasn’t such a bad intern to have around. Not only did I have a year under my belt, but I also was more procedurally savvy than most interns. I was able to do a lot of intubations, chest tubes, central lines, and other procedures without supervision. I switched into medicine with the idea that I would pursue a career in Pulmonary & Critical Care. I loved the Medicine Intensive Care Unit (MICU) and wanted to spend most of my time there. To be completely honest, I wasn’t particularly enamored with outpatient Pulmonology, although I did enjoy some of the more niche areas of Pulmonary Medicine including the HIV-associated and interstitial lung diseases. Just prior to applying for fellowship I was informed that I was selected to serve as one of the IM chief residents. That meant that I would need to put my applications aside for a year.

I then rounded shortly thereafter in the Cardiac ICU. At the time, I wasn’t particularly excited in a CICU rotation. But it didn’t take me long to fall in love with the CICU – and the acute heart failure population. I had the great fortune to round with 2 of the most influential faculty members and mentors in my career during that month in the CICU – Dr. Mark Drazner and Dr. Clyde Yancy. They made me love cardiology. They made me love acute heart failure. They also made me love the idea of clinical investigation and made me believe that I could challenge the status quo and help the move the field forward.

Along with Drs. Drazner and Yancy, I point to Dr. Hillis and to Dr. Daniel Foster – the inimitable Chair of Medicine at UTSW – as key mentors and role models in my pursuit of a career in Academic Medicine. Dr. Foster, in particular, impressed upon us what a gift it was to participate in the care of patients and their families. He made us all desire to become lifelong learners. He made us all want to be the best version of ourselves that we could possibly be.

2. As an academic leader and cardiologist-intensivist, could you share how you cultivated this interest and decided to work in this track?

After a 5-year stay in Dallas, I came to Durham, North Carolina for my Cardiology fellowship at Duke University. It was during my time at Duke that I became interested in cardiovascular critical care delivery. It was with the help of mentors like Dr. Thomas Bashore and Dr. Richard Becker that I was ultimately able to join the Division of Pulmonary, Allergy, and Critical Care Medicine at Duke to pursue an extra year of critical care training. This was no easy task; I will assure you. There was understandable skepticism about the career pathway upon which I was embarking. Many failed to see how I could parlay this training into a viable academic position. My mentors, however, reminded me that “vision is not seeing things as they are, but as they will be.”

I remember walking through the CICU at Duke early in my fellowship training and being struck by the acuity, the breadth of disease pathology, and the sheer burden of critical illness. This was no longer a specialized care unit for patients with acute myocardial infarction only – instead, it was truly an intensive care setting for patients with multisystem organ injury complicating their cardiovascular diagnosis. I felt that possessing both a broader skillset and broader understanding of critical care principles would serve me well if I hoped to take care of these patients for the remainder of my career. I was then fortunate enough to publish a perspective piece in the Journal of the American College of Cardiology, highlighting a potential role for the cardiology workforce in helping to tackle a growing critical care workforce shortage in the US. Following that, several colleagues and I published an epidemiologic study of nearly 2 decades worth of critical care trends within the Duke CICU. This highlighted the burgeoning complexity, illness severity, and influence of non-cardiovascular critical illness confounding the care of our patients. That paper, and its findings, helped me to realize that there was indeed value to my ideas and assumptions. I also believe that it was one of many studies that has helped to galvanize the field of Critical Care Cardiology.

3. COVID-19 has been life-changing in many aspects. How do you see training and practice in cardiology and critical care changing after that?

I believe that very few things will be the same following the COVID-19 pandemic. Though it will forever be linked to innumerable tragedies, the COVID-19 era has also revealed the fortitude, determination, pragmatism and the adaptability of our healthcare systems. I have been so impressed by colleagues – particularly those within the growing field of Critical Care Cardiology – who have developed and committed to innovative methods for enhancing care delivery, efficiency, and improved patient outcomes. I’ve been fortunate enough to have learned from and collaborated with critical care cardiologists from around the world – particularly from some of the most heavily impacted regions of the US, Europe, and Asia. This pandemic has led to partnerships that have been pivotal for developing novel and scalable models for healthcare delivery, for creating educational tools aimed at enhancing team training, and for designing key workforce adaptations. I think the COVID-19 pandemic has also shined an important light on the value of cardiologists with critical care expertise, along with other members of the multidisciplinary critical care team – including, but not limited to nurses, respiratory therapies, advanced practice providers, pharmacists, and others.

We’ve had to become considerably nimbler over time to meet the challenges we have faced. I believe this will serve us well moving forward, emphasizing the need to be malleable in our training and in the way we staff and organize our critical care units. I also think it has forced us to become more efficient in designing and implementing research efforts, using novel strategies and investigative platforms – all of this should help us in other areas of cardiovascular critical care, particularly those that require a team-based approach; examples of this might include cardiogenic shock, cardiac arrest, and refractory arrhythmia management, to name a few. Finally, anecdotally at least, I’ve seen a growing interest in our field among new trainees. Our younger colleagues see the value in this training and career pathway – magnified by the COVID-19 pandemic – and have been vocal about their passion. We must be prepared for a burgeoning group of future cardiologists who will want critical care training during their fellowship. In my opinion, that is a great problem to have

4. Do you advocate for training in critical care to be a track of advanced heart failure fellowship or a separate fellowship?

I personally advocate for flexibility. In my opinion, there should not be a “one size fits all” model to training the future critical care cardiologist. For those who want to practice in a variety of critical care settings, or who hope to advance the science of generalized critical care delivery, a full year of ABIM-sponsored training would likely be most prudent. I elected to take that route and am quite happy that I did. For others, however, the care of the critically ill heart failure patient is a primary focus. For still others, broader cardiac critical care training would be most desirable. I believe that if we rely solely on one training model, then we will never make up any ground in the monumental supply-demand mismatch that we are currently facing, and that I have alluded to previously. We also must acknowledge that many passionate trainees may bypass our field if training demands have too great an impact on things like financial solvency or family needs. Finally, it is important to acknowledge that there already exists a very large sex disparity in critical care cardiologists; if we have any hope of narrowing this gap and improving diversity, we have got to be more flexible when it comes to training options. I strongly advocate for enhancing diversity among our physicians to match the diversity we see with our patients.

5. Thank you for your leadership in cardiogenic shock management. How do you envision the epidemiology and treatment for this disease to be changing?

Cardiogenic shock remains a problem. Although we have improved our recognition and treatment options for this condition, still nearly 1 out of every 2 hospitalized patients will succumb to their illness. We have got to do better. That’s certainly a “glass half empty” look at the issue. A more “glass half full” vision would be that we are already learning a ton, there is much more we can learn, and we have the opportunity to dramatically impact a disease state with potentially catastrophic outcomes. You’ll recognize that no guidelines exist specifically for the management of cardiogenic shock. Sure, there are scientific statements and key opinion papers, but we need to accrue a greater and more robust evidence-base so that we can truly advance the field…and we are beginning to do just that.

It begins with speaking the same language. We need to be able to consistently identify, define, and risk stratify patients with cardiogenic shock. Some work by the Cardiogenic Shock Working Group, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions have helped to spearhead these efforts. Having a well-vetted classification scheme – like the SCAI shock stages – has certainly been important. How we implement these criteria in clinical and research efforts will be the real challenge. I’m optimistic though. I’ve seen unprecedented collaborative efforts to tackle cardiogenic shock, including novel partnerships between academic and non-academic settings. Prospective, and randomized trials will be crucial. And while figuring out which mechanical circulatory support device may be best for which patient, standardizing and studying care processes will – in my opinion – move the needle most substantially.

6. What do you think is the most rewarding part of your career? What do you recommend for FIT to consider when exploring further training in critical care?

Critical Care Cardiology, and Advanced Heart Failure/Transplant Cardiology for that matter, have both been quite humbling careers. One day I will leave the hospital feeling like the smartest man in the world. While the next day I can leave feeling like I don’t have a clue. I am, however, constantly reminded of Dr. Daniel Foster’s challenge to us trainees at UTSW – to be lifelong learners. I can say, without hesitation, that I am learning every single day. That is probably the most rewarding part of my career. I also very much enjoy the collegiality and camaraderie of the multidisciplinary CICU team. It has been amazing to see the field slowly mature, and particularly to hear from young trainees who have a passion to not only join our field…but to make it even better. I always make sure to find time for anyone that reaches out to me for mentorship. I’m not always sure how valuable my advice is, but I nonetheless want to make sure I can be helpful in any way possible.

7. What is most important for a FIT interested in this career pathway?

I said it above – mentorship. I would encourage trainees to reach out to those faculty members who share their interests; and they shouldn’t be constrained by the walls of their own institution. Many of us in the field thoroughly enjoy talking about our discipline, and will honestly share the good, the bad, and even the ugly. I have made so many friends over the years in North America and abroad. This field has allowed me to travel all over the world, and to be inspired on a daily basis. I feel incredibly fortunate, and yet I know there is so much more work to be done. I’m confident that it will be many of today’s FITs who will take Critical Care Cardiology to even greater heights.