Early Struggles, Notable Changes, and Ongoing Challenges in Cardiac Critical Care

One of the early pioneers in cardiac critical care, Dr. Jason Katz, director of cardiovascular critical care and co-director of mechanical circulatory support and the CICU at Duke University Medical Center, shares what motivated him to train in this field. We also discuss how to advance critical care research and future randomized controlled trials.

Dr. Amit Goyle:

On behalf of the entire CardioNerds team, we are beyond excited to bring to you the Cardiac Critical Care Series, to set the stage about this burgeoning field and its future directions with the Dr. Jason Katz.

This discussion is more than just a preamble to the comprehensive series. Rather, it is a call to action to redefine our training paradigms and reinvigorate the research efforts so that we can meet the demands of the modern cardiac critical care unit (CCU). With this impassioned background, over the next several episodes, we will take you through incredible cases in the CCU at the CardioNerds medical center, AKA the Schulman Ward, named in honor of Dr. Steven Schulman, the CCU director at Johns Hopkins University and beloved mentor, teacher, and friend to many CardioNerds.

This Herculean collaborative effort is brought to you by 18 expert faculty and 21 fellows from across several institutions and is led by series co-chairs doctors Mark Belkin, Karan Desai, Eunice Dugan, Yoav Karpenshif, as well as Dan Ambinder, and myself.

Dr. Mark Belkin:

Welcome, everyone, to the CardioNerds Cardiac Critical Care Series. This series is not just about an amazing alliteration but will be a deep dive into an incredible burgeoning field of cardiology.

As acute management of cardiac care continues to evolve, the field has moved beyond management of acute coronary syndromes and now encompasses, but are not limited to, more diverse ideologies of cardio shock for which a wide range of mechanical circulatory support options are available, postsurgical and postprocedural management and electrophysiologic manifestation.

As we take care of the sicker patients, cardiac and non-cardiac multi-morbid illnesses, it has become imperative to better understand critical care medicine as it relates to cardiology, specifically, from mechanical ventilation to renal replacement therapy in the effects of sedation. We are excited to bring together experts from across the field with the goal of improving education and cardiac critical care.

My name is Mark Belkin and I’m an advanced heart failure fellow at the University of Chicago. I am so privileged to serve as co-chair for the series along with two extraordinary fellows, Dr. Yoav Karpenshif and Dr. Eunice Dugan. Yoav and Eunice, it’s been amazing playing the curriculum with you both. Unfortunately, Eunice was unable to make it today as she is live in the cardiac ICU taking care of some critically ill patients, but we will have many episodes with her coming up.

Dr. Yoav Karpenshif:

Thanks, Mark. I couldn’t agree more. My name is Yoav Karpenshif. I’m a third-year cardiology fellow at the University of Pennsylvania and I’m so excited to be here. It seems only fitting to kick off the series with a true leader in the field, Dr. Jason Katz.

Dr. Katz is the director of the Cardiac ICU, Mechanical Circulatory Support and LVED Program at Duke University. After completing his internal medicine residency at UT Southwestern, he went on to complete a cardiology fellowship at Duke, a clinical research fellowship with the DCRI and finally, critical care fellowship at Duke. He has published over a hundred articles across a range of topics within cardiac critical care, including multiple reviews and statements addressing the role of and training options for cardiac intensivists. He is considered an early pioneer and continues to be a leader in the growing field, currently serving as the immediate past president of the AHA Acute Cardiac Care Committee. We are so excited to have Dr. Katz here to launch the series. Welcome to CardioNerds, Dr. Katz.

Dr. Jason Katz:

Yoav, thank you so much. It’s such a privilege to participate in this. Thanks to the entire CardioNerds team. I can tell you, I’m beyond excited to speak to you all today and it’s without an ounce of hyperbole at all that I can say that I’ve honestly been looking forward to participating in a CardioNerds podcast for a long time.

Dr. Belkin:

Dr. Katz, that is incredibly nice of you to say, and we are so excited to have you on this. There was really no one else we could have thought of to launch this series for us. And we were so excited to have you here for episode one.

So, Dr. Katz, you have been a leader in the field of cardiac critical care in the United States throughout your career. While it currently remains a small, though rapidly growing field, it was in a nascent stage when you embarked down this career path. What motivated you to choose this career pathway?

Dr. Katz:

Well, thanks for a great question. And I hope you’re prepared for a relatively long answer. I think there are a lot of things that motivated me to pursue this career pathway, indecision, curiosity. I saw it at the time, at least as an opportunity to perhaps differentiate myself and contribute uniquely to the field that I had already started to grow and love so much. Mentorship was really important in driving my career decision.

I’ll be completely honest with you. It took me a long time to figure out what I wanted to do with my life. And I might argue that now having just turned 47 years old, I still don’t know exactly what I want to be when I grow up. Like the field of cardiology, like the cardiac ICU, I think we all continue to grow and evolve. We identify that. We embrace that and I think it’s important not to be afraid of change in order to potentially succeed.

And I think what I’m about to say here is a relatively good tale for trainees listening to this recording. It’s okay to not entirely know what you want to do as long as you’re open to the possibilities, try to self-reflect and identify passions and then truly find mentorship and that was key. After medical school I began my training, believe it or not, at the university of Texas Southwestern as an emergency medicine intern, one of the very first classes of emergency medicine at UT Southwestern. This was in the very early days of emergency medicine as a unique discipline, to be honest with you. I enjoyed just about everything from a clinical rotation perspective that I experienced during medical school. I really enjoyed the breadth of disease pathology, acute care. I very much enjoyed hands-on procedures, thoroughly enjoyed the mystery in clinical decision making that came with the brand-new patient presentation of the emergency room.

I wound up having a great internship in emergency medicine at UT Southwestern. I learned a ton, had amazing colleagues, really gifted attending physicians, but I began to notice during that internship year that there was something a little bit odd about myself from a very early period on. After every exhausting ER shift, I’d head up to the ICU to see what was happening to the patients I had recently admitted. And it bothered me, really bothered me, to not know what, what was happening to those patients and how they did through their entire disease course. And when I’d look around my other emergency medicine colleagues would, appropriately so, empty their pockets at the end of the shift, head out of the hospital, try to do something to decompress and then prepare for their next long shift, but I wasn’t able to do it.

It became increasingly hard over that year. I couldn’t do it without some type of resolution from a patient care perspective. And that was probably the first and earliest suggestion that perhaps I might be doing the wrong thing. And then a little bit later, I was called into the office of the program director of the UT Southwestern Internal Medicine Residency. This was David Hillis, at the time, who was an incredible cardiologist and leader, longtime program director at UT Southwestern. And he told me, and I still remember this conversation clearly to this day, he said, “Jason, I hear you’re doing the wrong thing.” And I don’t think I said anything at the time to that response. I don’t think I knew how to respond to that. Then he followed it with, “You know, I’ve been told by many that you should be a medicine doctor, not an emergency medicine doctor and if you want a spot in our program, I can give you an intern position for the next academic year. Let me know.”

That was really the end of the conversation, and David Hillis, who’s on my list of people who I most admire in life and in medicine, offered me a prelim intern spot that would follow my emergency medicine internship, but he assured me as I was leaving his office that most years, a categorical spot at UT Southwestern would invariably open up. So, I left, and I wasn’t sure what to do, but I thought there was a lot of truth to what he had said and others had reached out to me as well. And I did a lot of soul searching, a lot of thinking about what I really wanted to do with my life. I realized, I think, eventually that Dave Hillis was right, and I wound up accepting a prelim spot in the internal medicine program.

Then several days before the new academic year started, Dr. Hillis called me and said, “Hey, a categorical spot opened up.” And he offered that to me and I of course accepted right away. So at least I knew that I had a pathway through internal medicine residency, and it wasn’t going to be let go after a prelim year. And then during the last days of my very first internship, my ER internship, I was an intern on a medicine ward service at Parkland Hospital and July 1st or maybe it was the second or third or fourth rolled around and my co-intern on that service became a second-year medicine resident while I became a medicine intern. And while to some that sounded probably pretty horrible, it was actually really an amazing year that second internship. And I’d argue that you spend a large bulk of your intern year learning to be an intern, and I didn’t have to do that.

So, for me, that second internship was purely about just learning and soaking and absorbing everything. It was fantastic. I think it was also nice, to be honest with you, for my senior residents who had an intern on their team that was capable of putting in chest tubes and innovating patients and doing things like that, but I took tons of notes. I soaked in everything that I could that year. Interestingly enough, those notes that I kept for a long time actually became the foundation for a book my colleagues and I published while I was in residency at UT Southwestern called the Parkland Manual of Inpatient Medicine and that’s just an aside. My goal at the time of entering that second internship was to become a pulmonary critical care doctor. I really loved critical care, the mystery, the procedures, the quick decision making, loved the teamwork, the ability to immediately alter the course of a patient’s illness trajectory.

I also, and this might seem a little odd when you think about it, but probably not if you think about it more deeply, I really enjoy the connections that I made with patients and families. Some will say, right, these patients are intubated. They’re sedated. You’re not going to have any type of relationship with them, but you really can. And particularly, with the families and loved ones, you have to build this trust with families and patients, and they have to build a similar trust with you. And I really enjoyed that. It’s not easy, but I enjoyed the challenge, the essential role of communication, even when things didn’t go as planned.

While I enjoyed critical care, I wasn’t nearly as enamored by outpatient pulmonary medicine. And I struggled a little bit with that, thinking about future career plan. And, shortly before I was to apply for pulmonary critical care fellowships, I actually was selected as a medicine chief resident at Parkland.

At UT Southwestern, the chief residency immediately follows residency. So, I had to put my applications, at the time, aside for another year. And then I was about to round in the Parkland Coronary Care Unit. And I’ll be completely honest, I was not excited about that. I really wasn’t the type of guy who I thought became a cardiologist. I wasn’t the type of guy that would fall asleep with a pile of ECGs under my pillow. I didn’t love quoting every 10 or 20,000 patient clinical trial, the acronym, the number of patients in each arm in acute ischemic disease, but and this is where I’m talking about the inspiration of mentorship, when I got into the Parkland CCU, I was met by none other than Clyde Yancy. And I tell you what is hard to work with Dr. Yancy and not want to be Dr. Yancy. Now, no one can be Dr. Yancy, but you can certainly follow in his footsteps and try to be like him in a number of different ways, particularly his passion and interest in clinical care teaching and clinical investigation.

And then after Clyde Yancy, believe it or not, I rounded with Dr. Mark Drazner, who became a real mentor of mine in heart failure. And this was a one-two punch of heart failure mentorship that I don’t think you could get anywhere else. And I just loved it. I was fascinated by acute heart failure and cardiogenic shock, in particular, from that moment forward. And then because of them, I became really interested in clinical investigation, as well. So, after that experience, and I challenge anyone to have that experience and not follow the same path that I did, there was no doubt that I wanted a career taking care of acute and advanced heart failure patients.

I arrived at Duke University for my fellowship planning to do just that, but it was difficult to take critical care completely out of me. And I truly enjoyed the rotations that I had in the CCU at Duke, but I noticed some things rounding in those units. What were once units purely for patients with acute MI clearly weren’t anymore. I noticed there was a ton of complex critical illness and a real need to better understand that.

I remember rounding with a number of different faculty members, but in particular, the former and perhaps future FDA commissioner, Rob Califf. And he asked me one day, “Why are we doing the same thing in this unit that we’ve been doing for a long time?” I don’t think I said, again, anything in response other than probably, I don’t know, but the comment really resonated with me.

This was no longer our fathers or grandfather’s coronary care unit filled with acute MI patients. What we were truly seeing was a group of patients with multi-system disease, receiving comprehensive critical care, who just happened to have cardiovascular ailments. I saw it as an opportunity to address something that no one had really focused on a whole lot, an opportunity to perhaps make a mark in medicine.

And I was supported also by other mentors like Rick Becker, who was at Duke University in the DCRI while I was training there. And he, himself, was in sort of an outside the box thinker who had trained in order to better understand coronary thrombosis, had trained as a cardiologist and as a hematologist. And he was the one that encouraged me to craft a white paper on the topic of cardiology and critical care.

We were fortunate enough to have that paper published in JACC and that started getting the ball rolling. And I decided from that point on that I wanted to train in both cardiology and critical care. And I started to focus on some research opportunities, really trying to just initially describe the contemporary landscape and things slowly, and I’ll emphasize slowly, but surely started to move forward at that point.

Dr. Karpenshif:

Thanks so much for sharing with us your amazing story, Dr. Katz. One aspect of cardiology critical care that is so exciting for me is how much it’s changing over time. And your career is a perfect example of that. I just would like to add that we’ve been lucky to have learned from both Dr. Yancy, and Dr. Drazner on CardioNerds and we totally understand how their mentorship must have been life-altering and career-affirming.

Dr. Katz:

Absolutely.

Dr. Karpenshif:

Dr. Katz, speaking of change in the field of cardiac critical care, what have been some of the most notable changes that you’ve seen since you’ve started? And thinking towards the future, what are the most important steps going forward for the field?

Dr. Katz:

That’s great. I think there have been quite a lot of changes. Unlike when I started, there’s now a growing critical mass of like-minded clinicians and investigators who are interested in the field and moving it forward. When I started and the few of us that started to galvanize the field, there was a lot of skepticism about whether we needed critical care cardiologists, what the role for these critical care cardiologists would be, where there would be a job market, et cetera. I think now that’s very different.

At that time, we felt a little bit alone. Now, there is clearly a growing mass of folks, including young faculty members, cardiac trainees, residents, medical students even that are really going to be critical to the evolution of this field. And in particular, it’s these young, thoughtful, curious trainees that have really already started to take the ball and run with it that I’ve been really amazed by that, so that’s been a huge change, I think, that there’s such a growing interest in this field.

These trainees have asked me questions that I never thought to ask. And it’s clear to me that while I’ve helped to shine a light on the field and others that you know of have as well, it’s they who are really going to take it to the next level.

What else has changed? We’ve started to see a lot more, at least, epidemiologic research coming out of the cardiac ICUs. We started to develop not just multi-institutional collaborations, but even multinational collaborations around cardiac critical care delivery. I think it would be a crime not to give a shout out to Dr. David Morrow and the team at the TIMI Group for helping to create the critical care cardiology trials network that has really done wonders for both describing the landscape and identifying potentially fruitful areas of investigation.

I’m particularly hopeful as an executive steering committee member of the trials network, that we’re going to then be able to leverage the outstanding huge registry platform that they’ve created to ultimately conduct prospective pragmatic trials, which will slowly change care practices so that we can take the hypothesis that we have identified in these observational studies and then truly test them in critical care populations, cardiac critical care populations in particular.

Obviously, there are certain patient groups that have been critical to the evolution of the field. I used to say, for a long time during their early parts of my career that the evolution in care within the CICU had blurred the margins between the CICU and the traditional NICU. And that was sort of something that I would show during all my talks and presentations and discussions early in my career. And that has changed, at least over the last sort of five to 10 years.

Now, I see the margins between the CICU and the NICU becoming clearer once again. The CICU is a very different critical care environment. And if anything, I’m starting to see the blending more cohesively between the medical cardiac ICU and the surgical cardiothoracic ICU. I, at the University of North Carolina ran both of those units. I attended both of those units at Duke University, and I think this cohesive state makes a lot of sense and our patients very frequently move back and forth between those two ICU settings.

And a lot of this, obviously, is being driven by cardiogenic shock and cardiac arrest management, the use of temporary and durable mechanical circulatory support strategies, structural heart interventions, hybrid electrophysiologic procedures and things of that like. Our patients are certainly getting more and more complex. We’ve seen that over time within the evolution of the CICU, greater illness severity. High expected event rates, meaning high morbidity and mortality.

And there’s a strong need to better understand these patients because of that high expected event rate. Evidence based and interventions may go a very long way and optimizing patient outcomes. Our patients deserve that we pay particular attention to that. We need more and more curious, passionate, and energetic people to enter the field. We don’t need only ask important and unanswered questions, but we have to figure out a way as a field to systematically address them. That’s a challenge developing and executing critical care research protocols. We need to understand the roles of these multidisciplinary team members.

I often say that there’s no greater team sport in cardiology than cardiac critical care. And I stand firmly behind that, but we need to understand how each member participates within the care of the patient to optimize outcomes. We need to understand how process impacts patients and how and if we can standardize this care across institutions. We must be willing to challenge the dogma and particularly the dogma that is often not rooted in substantial evidence, which you could say really for any intensive care unit.

We need clinical trials badly, especially randomized ones focusing on cardiac critical care populations. We need to be able to standardize terminology, which over the years has failed to be standardized in a lot of ways. We need to understand who belongs in the cardiac ICU, who doesn’t and when they can leave. And if they don’t need to be in there, how do we keep them out? And we need to understand how best to use our resources, contain costs.

We need to educate the community. I feel really strongly about this. We need to figure out ways to demystify the critical care experience for the community because patients and families come in there having no idea what to expect, no idea what the possibilities are, no idea what the limitations are. It’s a scary and unknown place for them. And I’m passionate about trying to figure out how to do that.

So, lots of changes I would argue, and some things haven’t changed a whole heck of a lot. So, there’s a need to not only understand and recognize the evolution of care in patients, but then, address them and try to standardize them and try to optimize them.

Dr. Belkin:

Oh man, Dr. Katz, what a call to action and change in the field. And it’s great to hear a vision of where this is going. And you brought up a lot of excellent points, many of which we are going to address throughout this podcast. So, I’m very excited.

You did reference in the question before this, you mentioned your JACC 2007 article that was titled Cardiology in the Critical Care Crisis. You wrote in there about the case mix of CCUs and the need to modernize training to staff them appropriately. And you also just talked about how it used to be a less of a differentiation between medical ICU and cardiac ICU and now maybe a little bit more blurred between cardiac ICU and cardiothoracic ICU.

Could you tell us what your concerns and predictions were then versus how they’ve played out now about 10, 15 years later? And do you feel that we’re still in a crisis?

Dr. Katz:

Thanks for the opportunity to address this. A lot of things happen in your career that are meaningful. That paper was quite meaningful to me. It was a real pivotal paper that I never thought would get published anywhere to be honest with you, I was encouraged by Rick Becker, who I had mentioned before, who was my clinical career mentor to craft this white paper on the need for critical care training within cardiology to address what was a burgeoning crisis of critical care, regardless of the subspecialty, the idea that there were increasing numbers of critically ill patients and not enough providers who are going to be available to take care of those patients. And I wrote that paper as a lowly second year cardiology fellow.

And for whatever reason, the Journal of American College of Cardiology decided to publish it, but it opened tons of opportunities for me and others. And for that, I am forever grateful.

I think a lot of what we wrote has come true. We’ve certainly seen an increase in critical care numbers and critical care populations. We’ve certainly seen the increase in illness severity that we had anticipated. There is still a huge supply/demand mismatch when it comes to patients and providers across critical care disciplines, but I think there’s a lot of things that I was hopeful that we’d have figured out by now that we haven’t and the best way that cardiology contributes to this, we’re working on it.

There’s a lot more people working on it now than there were 10, 15 years ago, but I recognize that it takes time. I’m not the most patient guy in the world, but I recognize that it takes time.

Now we have to figure out how to best train the next generation of critical care cardiologists. That’s something we talked about in that paper.

For that matter. We must figure out how best to educate trainees and other critical care disciplines if we really want to tackle the need for critical care providers across institutions. And we’re not just talking about academic institutions, we’re talking about larger nonacademic settings. We’re talking about smaller community settings, where there is going to be a mix often of general and cardiac critical care.

I wrote a paper with one of my former medical students while at the University of North Carolina, where we reached out and pulled general surgical and medical training programs in critical care medicine. We learned a lot about what people thought and their level of expertise or confidence, if you will, in taking care of cardiac critical care patients. And I’ll tell you that almost 90% of those that we polled; all those graduating trainees felt ill-equipped to help care for critically ill cardiac patients. So, if we were going to rely upon general, surgical, or medical critical care trainees to take care of our patients, we were going to be sorely disappointed. So, there’s got to be a way that we figure out how to help supplement their education as well.

And I also think that we need to be more aggressive about challenging the status quo. The idea, for instance, of adding yet another ABIM mandated training year for cardiology graduates just so they can take care of CICU patients is a tough pill to swallow. I did that. I finished up my cardiology training. I joined the pulmonary critical care medicine program for a year in which they crafted a unique critical care experience for me for a year. And then I did enough to sit for the ABIM Critical Care Boards, took the Critical Care Boards and then was board certified.

I don’t think that’s the only way that you have to do this, and I’ve come to that realization more and more as I’ve gotten older and participated in the care of CICU patients for long enough. I think there are other ways to train CICU cardiologists, CICU leaders.

Again, this idea of taking yet another year added to all the years that we’ve already done means deferring loan repayments, means putting strains on young and older families. It also means further delaying the enrichment of our workforce. I mean, there is a supply and demand mismatch that I and my colleagues on that paper truly highlighted that we’re facing and that’s getting worse and worse over time. And if we can’t figure out outside the box ways to train and enrich the critical care workforce, then we’re going to be in a big trouble.

We have to be able to think outside the box. You’ve seen some publications come out in some of the cardiology journals about figuring out ways to supplement heart failure and interventional cardiology training, for instance, to add critical care exposure. I think those are fantastic. Keep your eyes out, both in this most recent issue of the Journal of Cardiac Failure, as well as in future iterations of that journal.

There’s going to be some other exciting and novel ways that people have considered adding critical care training, embedding it within, for instance, heart failure training pathways.

I’m super excited about the issue of the Journal of Cardiac Failure that came out this month of October. It’s a theme issue looking at the nexus between heart failure and critical care. And I think there’s some unique ways to think about training that are in that journal. And I recommend people reading that.

As I mentioned, we’ve seen similar papers that have been in other journals, focusing on the interventional space in other areas. I’m excited about all these and it’s not about telling the ABIM what they need to do or how to do it, but I think understanding that things have changed over time, that we anticipated that, we’re seeing that, we’re going to continue to see that. And if we stick with the old ways, we’re never going to fix the problem.

And so, we need to also get the governing bodies of cardiology to get excited about these novel and outside the box training pathways as well, the ACC, the AHA, the Heart Failure Society of America. I think that’s the only way that we’re going to ultimately and proactively be able to manage this growing critical care crisis.

And again, it speaks to the enthusiasm and the innovation of the trainees that are currently in training, some of our junior faculty members and others that they’ve really come up with these unique potential solutions to what is an ongoing problem that I may have highlighted in 2007 but haven’t done a whole heck of a lot to fix.

In fact, when I get emails or calls about some of these ideas, when I read the papers, I think to myself, ‘what an idiot, I can’t believe I didn’t think of that.’ So, these are really great things and again, we just need to get people behind them because, to be honest with you, I don’t think it’s necessary to train in general critical care if you’re not going to be spending most of your time doing that. If you’re going to be focusing in the CICU or CTICU environment only, then I think there are ways to more specifically tailor the training to meet the needs of the patients that we’ll see in there. And I think there are ways to do it without further delaying graduation, without further deferring loan repayments, without adding to the burden of the years of training that our graduates are already facing.

Dr. Karpenshif:

Thank you so much, Dr. Katz, for that answer. You’re highlighting a lot of the things that we are seeing as trainees, having been through the general cardiology interview process recently and currently I’m interviewing many people who want to be cardiac intensivists for my training program. It’s very clear that there isn’t a standard template for how to pursue training in critical care cardiology. Flipping what you were just saying to the fellow’s perspective, do you have a certain pathway that you recommend and what are your thoughts about combining critical care with other subspecialties like interventional or advanced heart failure training?

Dr. Katz:

I suspect you could tell from my last response that I don’t think there’s necessarily a one size fits all model, and I think we should be malleable or adaptable to the needs of our trainees and the needs of our patients. Again, if we do things the way that we’ve always done them, all we’re going to do is continue to face a critical care crisis, the solution of which we won’t have addressed at all. Again, when I trained, as I mentioned, I joined Duke’s Pulmonary Critical Care Program for a year that allowed me to sit for the ABIM critical care exam. I had exposure to every critical care environment. I became board certified in critical care. I’ll tell you just recently, one of our trainees, Jeff Dixon, a fellow in cardiology at Duke actually did the same. The first duke cardiac critical care graduate since a guy named Katz.

And I think it’s great. And if you want to be able to care for patients in a variety of ICU settings, that’s a reasonable approach, currently the standard approach. But if we expect trainees to go through that pathway, it’s going to take forever before we have a qualified and stable workforce to lead our CICUs. We have to, as I previously mentioned, think outside the box, many institutions I think are doing things very differently right now. Every program has their own pathway established that meets the unique needs of their trainees and their institutional resources. It’s nice to see that there’s a growing number of options for trainees. When I was looking for an option, there weren’t very many that were available.

I’d love, however, for us to be able to unite as a cardiovascular community to really devise and endorse new ways to enrich the workforce, to be creative, to come with ways that will not only help our trainees, but will empower them, will improve diversity and the such.

I’m boarded in both critical care and advanced heart failure transplant cardiology. I sort of like that. I like being able to wear two different hats. I like the fact that when I’m not in the CICU, I can put on my hat as an advanced heart failure transplant cardiologist. And I think, for me, it was vitally important to avoid the potential for burnout and to diversify, in particular, my research interests. If I were to spend every single week in the cardiac or cardiothoracic ICU and to be sure sometimes it feels that way, but I think if I did that, I’d get tired. I’d lose focus. I’d lose some of my passion for the field and the patients. I enjoy my ambulatory heart failure experience. I really enjoy looking at a temporary and durable mechanical circulatory support devices and thinking about them from both clinical and investigative perspectives.

I imagine there are others that would probably feel fine just focusing on critical care. I think it’s a very individualized decision, and I think we should have the option of individualizing our decision. We put enough effort into our training, taking away from our families, deferring our financial security, that we should have an opportunity to be adaptable within our training pathways.

To be honest with you, there was a period of time. I thought after the end of my critical care training, I might do an additional fellowship in interventional cardiology. I thought it would be important to be able to place a number of these temporary MCS devices for the patients that needed them in my cardiac ICU. And there are people that have done that and done quite well. People like Ann Gage, who I respect more than most, whose career revolves around the care of critically ill patients and patients that need invasive and interventional procedures, but that really wasn’t for me at the time. I thought that if I was going to really focus on critical care cardiology, if I was going to try to drive this fledgling field, if I was going to do research in that area that I needed to at least spend a fair amount of time focusing on that, then I thought that blending that with advanced heart failure transplant cardiology made a lot of sense because there was a lot of overlap in the patient populations.

What I didn’t want to do is add on interventional cardiology and in my case, dabble in interventional cardiology. I didn’t think there was a patient alive that would be happy that I was dabbling in interventions with them. So that’s why I pursued the type of training and career that I did, but as I mentioned, I think there are individual options for everyone and everyone should have the right to tailor their training. And I think there’s not a one size fits all model that will address the crisis that we’ve been discussing.

Dr. Belkin:

I think you’ve given us a lot to think about the various ways that one can train to do cardiac critical care, whether that be on its own with heart failure, with interventional cardiology, but definitely a need to further, whether standardize or just continue to allow multiple options so that this field can grow.

Speaking of trainees, Dr. Eunice Dugan has joined the episode. She is coming off of a CCU call but is now able to join us post call. Eunice, how was your night?

Dr. Eunice Dugan:

Hey Mark, thanks so much for having me. I’m fresh off a night of CICU call. It was exciting as always. I think the series I was already excited to be part of it, but now that I’ve done a few more calls, I can see how this series is directly going to help. We had some pretty sick patients that we got through the night. So again, every time it’s an opportunity to see how much this field can really help people and getting the skills in this field can really be a huge boom to patients. So, I’m excited to be on here.

And Dr. Katz, it’s such a pleasure to reconnect. I know we initially met and talked together at the interview trail. I remember our conversation very well. Of course, you’ve done so much for this field and really are one of the leaders. And we’re so excited to have you on this series, excited to get to talk to you all today.

Dr. Katz:

Thanks, Eunice. It’s great to talk to you too.

Dr. Dugan:

I had a question that I would like to pose to you. Now, I’m into a few calls now and I have seen that many interventional cardiology and heart failure physicians actively attend in the CCUs.

How do you see critical care cardiology specialists partnering with other cardiologists like the subspecialties, interventional and heart failure in the management of complex critically ill patients?

Dr. Katz:

Eunice, that’s a great question. I’m a big fan of diversifying the faculty and leadership within the contemporary cardiac ICU. So, I’ve enjoyed including subspecialists in heart failure, interventional cardiology, electrophysiology, and others within the cardiac ICU, who’ve supplemented providers that are critical care trained. And those that may not be critical care trained, but have had years and in some cases, decades of experience taking care of critically ill cardiac patients. And I think that’s the best way, at least under the current circumstances, to take care of our sick cardiac intensive care unit patients.

At both institutions where I’ve helped run the cardiac ICU, I’ve tried to enrich the workforce within the cardiac ICU with the multispecialty providers and interventional cardiology and heart failure are clearly some of them.

We’ve seen this with a number of epidemiologic studies, and we all see this anecdotally, these units are becoming more critically ill and more filled with advanced heart failure, cardiogenic shock, and cardiac arrest patients in particular. The units that once started as units for patients with ST elevation myocardial infarction, or acute coronary syndromes are now filled with many other critically ill populations that have outnumbered the ACS patients.

In some institutions, STEMI patients don’t even go to the cardiac intensive care unit anymore. So, there’s a need for multidisciplinary expertise for sure. And interventional cardiology, heart failure and electrophysiology are some of those.

I mentioned this just previously, but I think part of the way that we’re going to address the growing supply/demand mismatch from providers to patient care is to empower heart failure and interventional cardiology trainees to be able to gain requisite skills in critical care so that they can feel comfortable attending in the CICU and even leading CICU teams, particularly if it’s of interest to them from a clinical and investigative perspective. And if not, attending in the unit is still a strong need for interventional cardiology, heart failure, electrophysiology physicians, to be key partners with critical care cardiologists or CICU cardiologists.

We have to be able to devise collaborative care plans together. And that doesn’t just mean meeting at the bedside to devise a plan and then scattering. It means following the patients throughout their critical care course, making sure and particularly the cardiogenic shock patients who require temporary mechanical circulatory support, it’s ensuring that they have a plan and that we’re constantly evaluating that plan. And that there’s an exit strategy, whether that be downstream resources like LVAD or transplant, whether that means palliative care, whether that means a high-risk percutaneous intervention or complex arrhythmia ablation, it means collaboratively managing the patients together.

And I oftentimes think of the critical care cardiologist as the conductor that helps to orchestrate the use of critical care resources, that helps to orchestrate discussions with families, but the partnership is key and because the partnership is so important, communication is so vitally essential. Ongoing dialogue is critical.

I can’t emphasize this one enough, but respect is so necessary. We have to respect each other and each other’s opinions, even if we don’t necessarily agree and have to come to a resolution. That makes critical care provision challenging, but it’s so important. And it’s so important for the patients to have a good outcome.

I’ve seen some institutions that have had and shared very successful cardio genetic shock programs, for instance, that leverage multidisciplinary collaboration with the CICU as the focal point. In most of these it’s clear that interventional cardiology and heart failure, along with surgery and critical care are the key leaders with leveraging other institutional resources as well, but it only works well if there’s a desire to work together and to improve outcomes together and to continuously evaluate the quality of the program. And I think that’s necessary whether you have a shock team or not within any cardiac ICU.

So that’s how I see the important partnership across cardiology subspecialties, ideally conducted or led by the critical care or CICU cardiologists because these patients are complex. They’re critically ill and they have often multi-system organ failure. I didn’t even include the non-cardiac subspecialists who are going to be key partners in the care of these patients. Many of our patients require continuous renal replacement therapy, many require prolonged invasive mechanical ventilation and ultimately will need tracheostomy. Many of these patients will have acute hepatic dysfunction. A large majority of our patients will have acute CNS pathology.

And so leveraging consultants that understand critical care delivery, nephrologists, critical care neurologists, hepatologists, et cetera, is going to be vitally important for anyone that attends in the cardiac ICU. It’s truly multidisciplinary care. It’s truly a team-based environment.

Dr. Karpenshif:

Thank you so much, Dr. Katz. Hearing your input about how the different specialties within cardiology and even those without need to interact with in the ICU really paints a picture of what this field can and should be. So far, we’ve been talking about the American experience. Can we learn from the European cardiac critical care experience as well? I know they have different training conferences and journals and are there plans under way to grow the field in a similar fashion in the United States?

Dr. Katz:

Yeah, this is great. I think, and I was guilty of this as an early trainee, I have this US centric view of the world of cardiovascular medicine. And it turns out that our European colleagues were way ahead of us on this. And I ultimately reached out to many of them early in my career. People like Susanna Price at the Royal Brompton in the United Kingdom and others just to get their support, but also to start thinking about how we might be able to leverage multinational collaborations.

The Europeans have had the Acute Cardiovascular Care Association for quite a long time. They’ve had their own scientific symposium, their own credentialing pathway. I’ve been lucky enough to participate in that conference, which is really outstanding. And again, focused on acute and critical care cardiology. They have a journal part of the European Heart Journal, family of journals dedicated specifically to acute and critical care cardiology.

I certainly think we can learn a lot from how they’ve tried to organize each other as nations within Europe. Many of us, like I said, have been fortunate enough to have been invited by our European colleagues that start thinking about how best to collaborate across the pond. I see exciting opportunities ahead, including we’ve talked about multinational mentorship programs, where some of our colleagues here and trainees here in the United States would be able to go abroad. Again, a little of this was pre pandemic planning, but hopefully they will occur in time, but some of our trainees go across to Europe to learn and be mentored by physicians in critical care cardiology there. And similarly, some of the trainees in Europe and in South America and other places come to train and be mentored by us here.

That will absolutely help to grow the field and help us to at least start to understand each other and standardize care and think about how we can standardize protocols, come up with unified hypotheses and test them in research.

There are many barriers also that our European colleagues have had to work through, and we can learn a lot from the struggles that they had. It’s helpful to have them have led the way. It’s one thing to understand their successes and utilize their successes, but we’re just as fortunate to know about what were challenges and be able to understand those challenges and hope to avoid some of the similarities here.

I’ve long actually said, CardioNerds team, that I’d love to take a sabbatical. I don’t know that sabbaticals actually still exist in academic medicine, but my sabbatical plan would be to travel across Europe and I know this sounds great, but travel across Europe and see how cardiac ICUs are being run. And one of the things I love about giving grand rounds, for instance, or being invited to other institutions is these institutions open the door to their house and you get a behind the scenes look on how things run, and you learn so much that you can then take back to your institution.

I’d love to do the same thing across Europe, travel to different cardiac ICU settings, see how they’re being run, understand similarities and differences. I think the understanding of that would be truly enlightening and traveling across Europe doesn’t sound like a bad sabbatical either.

In summary, I think there’s a lot we can learn from the European experience. There’s a lot of plans to try to organize from a multinational perspective. I think we can learn a lot from each other. We have different resources. We have different regulatory authorities. We have different settings for care delivery. So, understanding the differences are going to be important, but I think there are lots of opportunities to collaborate. So, I think those people that are interested in joining this field will have a real opportunity to collaborate across the globe. And I didn’t even mention some of our Asian colleagues as well. There are going to be really lots of opportunities to collaborate from a global perspective.

Dr. Belkin:

Wow. If you’re going on this world tour, I think I would be happy to go along, as would I think the rest of the CardioNerds. We could maybe launch a worldwide cardiac critical care series podcast, going to be like Rick Steves, but for cardiac critical care.

Dr. Katz:

That sounds perfect.

Dr. Belkin:

As we all go and learn together. Your last couple answers, you really brought back what you said right at the beginning is that you said there’s no greater team sport than cardiology in both the teamwork you’re talking about needed with interventional cardiology and heart failure, as examples and with specialties outside of cardiology and partnering with our international colleagues. All of that, which is great to hear, and I think one of the best things about not just cardiology, but cardiac critical care.

To pivot a little bit in terms of where you noted that some places where our European colleagues had excelled earlier is within the research space in this field. And so, one of the reasons I think we all love cardiology is a large body of evidence from which we can base our practice. Obviously, there’s a little bit less robust data within the cardiac critical care area. Pro side to researching critically ill patients can be difficult, particularly I think related to things like consent and combating physiological and theoretical assumptions versus standard care like we’ve all seen discussions, whether it be related to pulmonary artery catheters or Impellas or balloon pumps. How do you see cardiac critical care research going forward in the future to better answer some of these questions we have?

Dr. Katz:

This is a great question, Mark. This is a tough one, for sure. And probably why, if you look at my CV, it’s filled with key opinion pieces rather than hard evidence. It’s a little bit embarrassing to see that. Then I’ve told people I’m tired of talking about the way things should be and I want to be able to help address from an evidence-based perspective how they ought to be, but it’s tough. Doing research in any critical care setting is extremely challenging.

And you describe several reasons for that, with challenges about assumptions and the consent process, et cetera, and not to mention there isn’t, at least in critical care, for when you’re talking about heterogeneous critical care populations, so there isn’t often a distinct pathophysiologic target that we can challenge for our patients and improve outcomes.

These are heterogeneous individuals with heterogeneous baseline characteristics, numerous comorbidities, variable illness severity, differential treatment responses, et cetera. And we’re also, you could argue, even within our own institutions and Duke’s no different, quite heterogeneous in our processes of care and the way we take care of our patients. I think you could pull out one patient with cardiogenic shock and have five different CICU attendings and decide to manage them with five different combinations of vasoactive and mechanical circulatory support strategies.

I think we have work to be done, but we’re starting to make some strides. I think, again, alluding back to the work that Dave Morrow and the TIMI Group did about establishing the critical care trials network has helped. We’ve started to outline ways where we can start thinking about prospective research. The work that’s been done with some of my colleagues in the cardiogenic shock working group, outstanding and then there are other groups as well.

They’ve all started to identify potential hypotheses that then can be translated into pragmatic questions and that then can be tested in our CICU population. I think, Mark, we have to start pretty simple. I think we have to tackle simple questions, devise simple and standardized protocols. I’d argue we must collect as much data as we can on everything when we execute these protocols and do these clinical trials, patient characteristics, all of the care within the intensive care unit that is being provided, et cetera.

We need to find ways to address care disparities. We need to find ways to enhance representation of underrepresented patient populations. That’s going to be vital because failure to do that will mean failure to understand the influence of care on really large groups of patients who may respond quite differently to critical care interventions. And we need to be proactive.

We got to work together. I think that the single institution observational studies that I’m guilty of performing and populating my CV with both times right to move beyond that. So, for instance, in the durable VAD world, in which I participate, we’ve been inundated with these single institution studies for years.

I’m, again, a guilty party of that, but only now are we starting to do those pragmatic randomized placebo control trials for these patients outside of device trials but looking at best care practices. You can’t fall in love with these single institution approaches in the CICU. And I tell many people, and again, this is something I continue to struggle with as I look at myself in the mirror at night, I’m tired of writing about what I think should happen. We need to figure out what absolutely should happen by employing rigorous research and methodology. And I think it’s going to take a really forceful collaborative approach to figure these things out. And I think we’ve got a good start, but I think we need to really push the field forward with prospective research.

Dr. Dugan:

Yes, Dr. Katz, thank you so much for your opinion on that. I totally agree. Now we’re in recruitment season and I was wondering how would you advise an internal medicine resident interested in critical care cardiology regarding choosing a fellowship? Now we know this is still a pretty new field. What do you think are the components of a successful cardiology critical care training program?

Dr. Katz:

I think, Eunice, to be honest with you, it’s still most important, in my opinion, for an internal medicine trainee who’s moving on to fellowship to find a fellowship that will train them to be a great general cardiologist, that will equip them with all the skills necessary to understand the complexities and the diverse pathology of cardiovascular disease, one that will power them to be leaders in whatever field they ultimately end up pursuing.

If I’m a case example, a guy that went to medical school thinking he would be a pediatrician, then decided he was going to be an emergency medicine doctor, then suddenly decided to be a pulmonary critical care doctor, then a heart failure doctor, then a critical care cardiologist with heart failure expertise. If I’m the case example, there are lots of opportunities to change your mind. And so, I think I was blessed to have opportunities because I got a great general training experience, both in residency and in fellowship. And I think that’s vitally important. And I think it’s essential to be exposed to the breadth of which cardiology has to offer.

Why, I’d love for any IM resident to join me in the field of cardiac critical care and I hope many that listen will. I think they’d be doing a disservice to themselves if they didn’t consider all the amazing opportunities that cardiology has to offer. And that’s something I would recommend very early and there, of course, many other things to consider, many of which you guys have considered. I certainly consider geography, the flexibility of the curriculum, the overall fellowship and social experience, the clinical setting, everything that’s important to choosing a cardiology fellowship.

And more important in my mind than if they have a standardized cardiac critical care pathway is to understand the culture of mentorship within the fellowship to understand that they have or are willing to embrace novel training opportunities.

I was lucky to operate in an institution which was willing to embrace this outside the box thinking even if they didn’t quite understand why the heck I would want to do it. Finding mentorship is critical, pardon the pun. And as I mentioned, that’s the only way that I happened upon the field. I had good mentorship.

For those interested in academic pursuits, understanding, obviously, the opportunities for research training during fellowship is key. And again, it’s not just about can I do research in the field of cardiac critical care? It’s about honing the necessary skills, developing the skillset necessary to perform, to execute, to lead clinical research endeavors.

Anyone is obviously more than welcome to reach out to me via email as well. I’ll be happy to add my two cents to anyone’s training pathway, but everyone’s situation is very different. I also think that it’s very important to acknowledge that mentorship and collaboration can happen even during fellowship outside of the walls of your own institution. I did this.

So just because you may not have a critical care cardiology expert at the institution that you’re training at, that doesn’t mean that there’s not opportunities to get mentorship from afar. I, during my training, reached out to faculty members from across the country and the world for that matter. Probably most of my emails were met with complete silence, but some were followed by great conversations and collaborative opportunities. Some were followed by phone calls, even the occasional, “I think you’re on the right track, Jason” comment was enough to keep me moving forward.

So, it’s essential that I think people are not afraid to look for help elsewhere. That’s how I would emphasize things for an internal medicine resident looking to join the field. Look for the places that feel right. Look for the places that are going to give you the best and broadest cardiovascular training. Look for the places that if you’re interested in an academic or investigative career will equip you with that skillset. Look for the places that have a rich history of mentorship and then not be afraid to reach out outside the walls of your institution for additional mentorship. That’s how I would suggest an IM resident approach things.

Dr. Karpenshif:

Thank you so much, Dr. Katz, for that. And as a fellow who’s towards the end of my training and very busy just having this conversation with you and thinking through this field, the future, how it’s changing and what it looks like and especially the points you made about mentorship is so life-affirming and making me truly excited to become a part of this field.

Dr. Katz:

That’s fantastic. I’m glad to hear it.

Dr. Dugan:

Dr. Katz, we have a tradition here in CardioNerds and now that we’re starting off the Critical Care Series, we’re going to continue this tradition and that’s asking our invited speaker a very important question. We’d love to know what makes your heart flutter about caring for critically ill patients in the cardiology intensive care unit.

Dr. Katz:

That’s a great question, Eunice, there are a lot of things. I’ll tell you; I still get excited. I still get nervous every day that I show up in the cardiac ICU. I’ve got this nervous energy, this constant butterflies in my stomach about what I might see, what I might be exposed to. Will I know everything? I always learn something new in the cardiac ICU and that gets me both excited and nervous.

I remember the feelings constantly when I’m in there of going home some nights after a busy day in the cardiac ICU, feeling like I can take over the world. I can conquer any disease that threatens to challenge me at all. I can do no wrong. And then that is almost invariably followed by the next night where I feel like I let my patients down, like I couldn’t do anything right and that’s humbling, but it keeps me energetic. It keeps me reading. It keeps me trying to learn. It keeps me working hard. And I think that’s exciting about being a cardiac ICU clinician.

As I mentioned before, I really enjoy the team approach to care. And I love that we have a great multidisciplinary team in the Duke cardiac ICU. We recently added some seasoned advanced practice providers to our CICU team at Duke. I’ve already learned a ton from them and I’m hopeful that they learned a ton from me. I constantly learned from our trainees. It’s hard to keep up with general medical information in particular and the medical students, residents and fellows are quite happy to teach me what I don’t know. And I’m quite happy to say I have no idea what you’re talking about. Please share with me.

I also love that every day I round I can think of about 10 questions or more that need to be asked and answered of our care in the cardiac ICU. I remember being a cardiology fellow trying to come up with research ideas and I would stay up at night hoping that by some divine intervention, I’d come up with some great topics, some great question to ask from a research standpoint and most nights I’d fall asleep without a single question. Now, I’m inundated, if not persecuted, by the numbers of questions that exist in the care of cardiac ICU patients. And that’s really great.

I’ve actually told our trainees and I still plan to do this, but I haven’t quite done this yet that I actually want to put suggestion boxes at both ends of our cardiac ICU, kind of the Journal of Heart Hospital Medicine Series that’s so popular. I want to label these boxes “Things we do here for no good reason.” And I’ve encouraged everyone, nurses, doctors, pharmacists, RTs, social workers, everyone to contribute. And I think if we open up that suggestion box every now and then we’ll learn a ton because there are tons that we’re doing in those units with very limited evidence based and in many cases with no evidence to support them. And I bet we can use some of these ideas to proactively improve care in the cardiac ICU.

But mostly, though, I’m excited about the trainees and the trainees that hope to become the next generation of critical care cardiologists. They’re the ones that are going to truly change the world. And I really enjoy watching them get excited about care, watching them become passionate about the field. So that’s a long winded an answer to say that there are many things that make my heart flutter still in critical care cardiology, but in particular, it’s the next generation that makes me excited and feel a bit old.

Dr. Belkin:

Wow. What an incredible answer. This has been an amazing time. We’ve heard about your story and within that, the story of cardiac critical care. We’ve heard about the growth of the field from training programs to different ways to work collaboratively, the seemingly myriad options for future research and now even the idea of the suggestion box in the ICU that we might have to bring on Monday as well. And finally, the importance of teamwork. Dr. Katz, it has really been an amazing time speaking with you and thank you for taking the time. We are so excited that this 16-episode series is soon going to be launched with this episode. And we have many fantastic episodes coming off that are again co-chaired by the amazing fellows, Dr. Karan Desai, Dr. Eunice Dugan and Dr. Yoav Karpenshif and of course, our co-founders Dr. Amit Goyle and Dr. Dan Ambinder. We excited to bring you shock, mechanical circulatory for arrhythmias, sedation, renal replacement therapy and everything in between. So, thank you, again, for joining us.

Dr. Katz:

Thank you so much for the opportunity. It was an absolute honor and privilege and I for one am really looking forward to the next several sessions to learn more about cardiac critical care.

CardioNerds is an independent fellow-founded platform with a mission to democratize cardiovascular education. The views expressed here do not necessarily reflect the opinions or policies of our employers.

*This podcast transcript has been edited for clarity and brevity.