Non-interventional cardiology scope of practice

[JPSmyth]

I have been searching the internet and these forums specifically but I haven't been able to find a straightforward answer to my question.

It is my understanding that the main types of cardiology are: non-invasive, invasive, interventional, and EP. Non-invasive doesn't work in the cath lab at all, invasive does imaging in the cath lab, interventional places stents and fixes things via cath, and EP does implants and other procedures. Is this somewhat accurate?

My main question is that after an IM residency -> 3 year cardiology fellowship, can one practice as an invasive cardiologist? or solely non-invasive? Non-invasive and invasive are the two fields that interest me more so than interventional or EP with their extra fellowships.

Let's say a resident completes 3 years IM and 3 years cardiology fellowship (2 clinical and 1 research year I think is standard of cards most programs), will he/she be able to practice as either a non-invasive or an invasive cardiologist? And what might their scope of practice look like?

Thank you!

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[IM2GI]

Im not a cardiologist, the idea of a "diagnostic cath" seems like malpractice to me. If you are going shoot dye in coronary arteries, be able to deal with what you find.

 

[Powerplant1]

I have been searching the internet and these forums specifically but I haven't been able to find a straightforward answer to my question.

It is my understanding that the main types of cardiology are: non-invasive, invasive, interventional, and EP. Non-invasive doesn't work in the cath lab at all, invasive does imaging in the cath lab, interventional places stents and fixes things via cath, and EP does implants and other procedures. Is this somewhat accurate?

My main question is that after an IM residency -> 3 year cardiology fellowship, can one practice as an invasive cardiologist? or solely non-invasive? Non-invasive and invasive are the two fields that interest me more so than interventional or EP with their extra fellowships.

Let's say a resident completes 3 years IM and 3 years cardiology fellowship (2 clinical and 1 research year I think is standard of cards most programs), will he/she be able to practice as either a non-invasive or an invasive cardiologist? And what might their scope of practice look like?

Thank you!

3 years IM and 3 years of cardiology and you can practice as invasive cardiologist. In my fellowship these guys don't do procedures -- they refer to their interventional colleagues. They even refer for things like right heart caths which are solely diagnostic. Where I did residency, it was 180 degrees opposite. Everyone did their own diagnostic caths and if intervention was needed, they let the interventionist on call know, and he hopped in and placed the stent. So basically it totally depends on practice type. Some places there are no real "invasive" guys and in others there are. Usually depends on pay model and size. Regardless which one, neither is bad practice or "malpractice" and diagnostic caths are common.

 

[JPSmyth]

3 years IM and 3 years of cardiology and you can practice as invasive cardiologist. In my fellowship these guys don't do procedures -- they refer to their interventional colleagues. They even refer for things like right heart caths which are solely diagnostic. Where I did residency, it was 180 degrees opposite. Everyone did their own diagnostic caths and if intervention was needed, they let the interventionist on call know, and he hopped in and placed the stent. So basically it totally depends on practice type. Some places there are no real "invasive" guys and in others there are. Usually depends on pay model and size. Regardless which one, neither is bad practice or "malpractice" and diagnostic caths are common.

Thank you very much for this insight. Is it common for people to complete the three year fellowship and then begin practicing?

 

[Powerplant1]

Thank you very much for this insight. Is it common for people to complete the three year fellowship and then begin practicing?

yes, I don't know percentages overall but it is common.

 

[JPSmyth]

yes, I don't know percentages overall but it is common.

Thank you!

 

[IM2GI]

3 years IM and 3 years of cardiology and you can practice as invasive cardiologist. In my fellowship these guys don't do procedures -- they refer to their interventional colleagues. They even refer for things like right heart caths which are solely diagnostic. Where I did residency, it was 180 degrees opposite. Everyone did their own diagnostic caths and if intervention was needed, they let the interventionist on call know, and he hopped in and placed the stent. So basically it totally depends on practice type. Some places there are no real "invasive" guys and in others there are. Usually depends on pay model and size. Regardless which one, neither is bad practice or "malpractice" and diagnostic caths are common.

Im not saying legally its malpractice. Just seems absurd to me, and I wonder if the patients are really informed that the person doing their procedure wont actually fix something and they will need to go through the risks of the procedure again.

It would be like me doing a colonoscopy, finding polyps, and leaving them in and saying ok go see the next guy to have this done again. Just seems like a poor use of resources to me.

 

[Powerplant1]

Im not saying legally its malpractice. Just seems absurd to me, and I wonder if the patients are really informed that the person doing their procedure wont actually fix something and they will need to go through the risks of the procedure again.

It would be like me doing a colonoscopy, finding polyps, and leaving them in and saying ok go see the next guy to have this done again. Just seems like a poor use of resources to me.

In my n=1 experience they are told that if something is found someone else will come in and fix it. The patient doesn't get off the table and come back the next day. The access sheaths stay in place and the patient stays on the table.

I don't disagree it's a poor use of resources at time but on the other hand, you are fully trained to remove polyps right out of fellowship while cardiologists aren't trained in intervention after 3 years. But they are well trained to do caths. Where I did IM, it was all about money. The general guys wanted to keep doing their own caths because as you know, procedures pay the bills.

Guess the closest thing I could think of in GI, which I'm obviously not super familiar with, would be you go in to do a biopsy and path shows nothing so a partner that does advanced endoscopy goes back in and uses EUS to get better tissue. Then again, where you are everyone may do that. Where I did residency only certain ones did. Same with ERCP.

 

[nlax30]

In general, you can do invasive, "non-interventional" cardiology coming out of a 3 year Cards fellowship. If so then it's just a matter of getting the proper number of procedures (caths and/or pacers) and experience during your fellowship.

Like has been said above it varies widely out in the real world what a general cardiologist actually continues to do. Where I did general fellowship we had a couple general cardiologists that were sort of the old-school invasive non-interventional types that did diagnostic caths and one that also did pacemakers. Most of the general guys also did TEEs.

Since it was brought up above.... I tend to agree in that a cath being done with high likelihood of finding obstructive CAD should probably just be done by the interventionalist, ie Acute coronary syndromes, markedly positive stress, etc... Though a good number of caths never end up needing intervention and sometimes the interventional guys are covering multiple hospitals and STEMI call so there's certainly the volume and need for non-interventionalists doing caths. We had a lot of pre-op CV surgery and valve cases that all needed diagnostic only caths, not too mention the ones where you have a pretty good educated guess that you won't find anything.

So coming out of a 3 year general fellowship it's certainly possible to be able to do diagnostic caths, TEEs and pacemakers. Obviously for stents/structural heart cath work would need to go the Interventional pathway and for more advanced devices (ICDs/CRTs) as well as arrhythmia ablations the EP pathyway. I know one interventionalist who did a "device year" and does pacers/ICDs/CRTs.

 

[IM2GI]

In my n=1 experience they are told that if something is found someone else will come in and fix it. The patient doesn't get off the table and come back the next day. The access sheaths stay in place and the patient stays on the table.

I don't disagree it's a poor use of resources at time but on the other hand, you are fully trained to remove polyps right out of fellowship while cardiologists aren't trained in intervention after 3 years. But they are well trained to do caths. Where I did IM, it was all about money. The general guys wanted to keep doing their own caths because as you know, procedures pay the bills.

Guess the closest thing I could think of in GI, which I'm obviously not super familiar with, would be you go in to do a biopsy and path shows nothing so a partner that does advanced endoscopy goes back in and uses EUS to get better tissue. Then again, where you are everyone may do that. Where I did residency only certain ones did. Same with ERCP.

Your model makes sense for sure. When I was a hospitalist for a year in between fellowship there were guys out in the community doing diagnostic caths, and then transferring them to the University hospital when they found stuff to intervene on. Always drove me nuts and seemed like a total cash grab.

 

[nlax30]

Your model makes sense for sure. When I was a hospitalist for a year in between fellowship there were guys out in the community doing diagnostic caths, and then transferring them to the University hospital when they found stuff to intervene on. Always drove me nuts and seemed like a total cash grab.

Yea certainly could be. I think there definitely is some component to guys not wanting to let go or miss out on that income though there is also an aspect of rural/community hospitals opening cath labs and 'forcing' groups to staff it there just may not be enough support in that area interventionalist-wise to support it and so they have to rely on general guys doing some of the cases thinking that likely the majority of them are not going to need intervention. So I see both sides. I can certainly see the need in certain areas, though in a more urban or suburban setting where there may be a dozen interventionalists then I think they should probably just be doing those cases. I've seen many times where the patient lays around for a few hours with sheaths in waiting for the a stent after their diagnostic cath.