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Role of Critical Care Medicine Training in the Cardiovascular Intensive Care Unit: Survey Responses From Dual Certified Critical Care Cardiologists

Background Cardiovascular intensive care units (CICUs) have evolved from coronary care wards into distinct units for critically ill patients with primary cardiac diseases, often suffering from illnesses that cross multiple disciplines. Mounting evidence has demonstrated improved survival with the incorporation of dedicated CICU providers with expertise in critical care medicine (CCM). This is the first study to systematically survey dual certified physicians in order to assess the relevance of CCM training to contemporary CICU care. Methods and Results Utilizing American Board of Internal Medicine data through 2014, 397 eligible physicians had obtained initial certification in both cardiovascular disease and CCM. A survey to delineate the role of critical care training in the CICU was provided to these physicians. Among those surveyed, 120 physicians (30%) responded. Dual certified physicians reported frequent use of their CCM skills in the CICU, highlighting ventilator management, multiorgan dysfunction management, end‐of‐life care, and airway management. The majority (85%) cited these skills as the reason CCM training should be prioritized by future CICU providers. Few (17%) agreed that general cardiology fellowship alone is currently sufficient to care for patients in the modern CICU. Furthermore, there was a consensus that there is an unmet need for cardiologists trained in CCM (70%) and that CICUs should adopt a level system similar to trauma centers (61%). Conclusions Citing specific skills acquired during CCM training, dual certified critical care cardiologists reported that their additional critical care experience was necessary in their practice to effectively deliver care in the modern CICU.

T here is growing evidence that cardiac intensive care units (CICUs) have evolved from coronary care observation wards into units that comprehensively care for critically ill patients with primary cardiac problems and complex multisystem illnesses. The American Heart Association released a scientific statement in 2012 detailing the need for CICUs with dedicated critical care cardiologists as well as potential shifts in training strategies for aspiring CICU physicians. 1 The American Heart Association statement outlines the existing Accreditation Council for Graduate Medical Education training paradigm, which includes 4 years of fellowship with a minimum of 30 months of clinical training, 6 of which must be dedicated to critical care medicine (CCM). The American College of Cardiology Core Cardiovascular Training Statement Task Force has also recognized the need for advanced training opportunities, describing 3 levels of critical care cardiology proficiency. 2 The Task Force specifies that level I should be obtained during a general cardiology fellowship and should be sufficient to care for the majority of CICU patients. Level II can be achieved with an extra 3 to 6 months of critical care time and level III with an extra 12 months of critical care time. The Task Force only highlights endotracheal intubation and intra-aortic balloon pump placement as patient care milestones and no evaluation processes are specified, indicating that competencies for the practice of advanced critical care cardiology need to be further delineated.
There have been numerous publications, aiming to characterize the added value of critical care cardiology training. CICU providers are exposed to an increasing amount of noncardiac pathology, including sepsis, renal failure, and respiratory failure requiring prolonged mechanical ventilation. [3][4][5][6][7][8] Moreover, patients with these noncardiac complications have longer CICU lengths of stay and a higher risk of mortality. 6 Transitioning to a high-intensity staffing model, which incorporates dedicated critical care cardiologists or regular consultation with CICU-based noncardiology critical care physicians may be associated with reduced mortality, length of stay, and costs. 9,10 However, dual trained critical care cardiologists remain few in number, with a recent survey identifying only 8.7% of hospitals utilizing them as unit leaders and only 14.7% of hospitals with at least 1 critical care cardiology attending. 11 Similarly, an investigation of the Doximity physician database reported that only 0.47% of CICU admissions were treated by dual certified physicians and that only 3.4% of the identified dual certified physicians were female. 12 Despite these data, the perceived priority of fostering critical care trained cardiologists remains a topic of debate, prompting numerous letters and editorials. [13][14][15] Though numerous studies have described the current organizational structure and staffing of modern-day CICUs, no previous study has systematically surveyed practitioners with American Board of Internal Medicine certification in both cardiovascular disease (CVD) and CCM. Thus, we sought to better understand how these American Board of Internal Medicine dual certified critical care cardiologists have utilized their training, and how they fit into the evolving critical care landscape.

Methods
This research activity was designated exempt from institutional review board review by the Office for Human Research Protections at the National Institutes of Health. The original survey is available within Data S1. The data that support the findings of this study are available from the corresponding author upon reasonable request.
Through 2014, the American Board of Internal Medicine granted initial certification in both CVD and CCM to 563 physicians. After excluding 5 deceased physicians, 4 physicians under disciplinary action, 21 physicians retired or without valid medical licenses, and 136 physicians without registered emails, the analysis sample of 397 physicians remained ( Figure 1). A questionnaire to delineate the role of additional critical care training in the setting of cardiology training was provided to these dual certified physicians by e-mail invitation, using REDCap (Research Electronic Data Capture) data capture tools hosted at University of California San Francisco. 16 REDCap is a secure, web-based application designed to support data capture for research studies, incorporating data entry, auditing, and import/export procedures.
Survey data were augmented with key American Board of Internal Medicine administrative data. Variables derived from the administrative data included practice location, age, gender, an indicator variable for passing both CVD and CCM initial certification exams on the first attempt, and an indicator variable for obtaining CCM certification through the practice pathway. CCM certification through the practice pathway was possible during the first 3 years of exam administration : 1987, 1989, and 1991. No fellowship training in critical care medicine was required as long as applicants documented that they were currently providing critical care, and they had previously certified in internal medicine. Because these practice pathway physicians and those having completed fellowship training in CCM potentially represent distinct groups with divergent training and unique insight, they were separated for a subgroup analysis. We used chi-square tests to examine whether responders differed from nonresponders in regard to demographic variables (Table 1). To adjust for possible nonresponse bias, we used propensity score weighting with poststratification. 17 Subjects were assigned a poststratification weight after being divided into quintiles based on estimated propensity scores. Estimated propensity scores were computed with a logistic regression model containing an indicator variable for survey response as the outcome, along with practice location, age, gender, an indicator variable for passing both CVD and CCM initial certification exams on the first attempt, and an indicator variable for obtaining CCM certification through the practice pathway as predictors. Descriptive statistics of survey results were reported based on the calculated propensity score weights. Analyses were conducted using SAS software (version 9.4; SAS Institute Inc, Cary, NC).

Results
Among the 397 eligible physicians, 120 (30%) responded to the survey. As seen in Table 1, responders were more likely to be aged <60 years than were nonresponders (30.9% versus 20.9%; P=0.03). They were also more likely to pass both CVD and CCM initial certification exams on the first attempt (87.5% versus 75.8%; P=0.01). Though the 2 groups were otherwise comparable, there was a notably small number of female dual certified physicians, making up only 3.3% of the analysis sample.
The majority of the critical care cardiologists in the analysis sample obtained CCM certification through the practice pathway (n=273; 68.8%), with substantially fewer completing CCM fellowships (n=124; 31.2%). Compared with physicians with CCM fellowship training, the practice pathway physicians were more likely to be aged >60 (93.4% versus 37.9%; P<0.001) and more likely to pass both CVD and CCM certification exams on their first attempt (83.5% versus 70.2%; P=0.002; Table 2). There were no significant differences between the practice pathway and CCM   Figure 2). A similar pattern for additional subspecialty training was observed in both those with CCM fellowship training and those certifying through the practice pathway, with a trend toward increased subspecialization in the CCM fellowship trained group.
A total of 64.9% agreed that they would train in both cardiology and CCM again if granted the opportunity to do so (95% CI, 55.6-74.1%). Interestingly, this sentiment was far more robust among CCM fellowship trained physicians than those having completed the practice pathway (91.5% versus 50.9%; P<0.001). As a whole, the survey group supported this position by reporting that they used their CCM training on a regular basis. Sixty-one percent responded that they used CCM training either "regularly" or "all the time" in their current practice (95% CI, 51.6-71.1%). The CCM fellowship trained group had a higher proportion reporting regular use of their skills than the practice pathway group (78.8% versus 52.2%; P=0.01; Figure 3).
Critical care cardiologists were further asked to identify the specific CCM skills most essential to the effective management of CICU patients. They highlighted ventilator management (55%), multiorgan failure management (50%), end-of-life care (43%), and airway management (41%). ICU sedation, infection management, and ICU nutrition were also frequently selected as relevant clinical areas ( Figure 4). The relative hierarchy of importance regarding these skills was similar between the CCM fellowship trained and practice pathway groups (r spearman =0.92; P<0.001); however, the CCM fellowship trained physicians selected a higher number of skills, on average (8.3 versus 3.7; P<0.001), which likely accounts for much of the intergroup differences observed in Figure 4.   outcomes as the reason to prioritize critical care training ( Figure 6). Lastly, the majority of dual certified critical care cardiologists supported the adoption of a trauma-center-like level system for CICUs. We found that 61.2% were in favor of adoption (95% CI, 50.9-71.6%), 13  Those fellowship trained in CCM were more likely to agree with the transition to a CICU-level system than were those who certified through the practice pathway (76.7% versus 52.8%; P=0.01; Figure 7).

Discussion
The present study surveyed physicians with dual certification in both CVD and CCM with the aim of better understanding their collective perspectives and experiences. These cardiologists have unique insight into the importance of additional critical care training and its relevance to CICU patient care in their practice. Current critical care cardiologists, both CCM fellowship trained and practice pathway certified, described using the skills that they obtained by critical care training regularly, albeit the fellowship trained physicians had a higher proportion using those skills on a regular basis. Furthermore, they highlighted the specific CCM skills that are most fundamental to patient care in contemporary CICUs. Greater than 40% of responders selected ventilator management, multisystem organ failure management, airway management, and end-of-life caretopics that are not adequately emphasized in general cardiology fellowships.
The applicability of these CCM skills to CICU daily workflow is a potential driver of the improved patient outcomes that have been observed in recent studies. 9,10 The most intriguing study, by Na et al, 9 described patient outcomes before and after the CICU was converted to a comanaged unit with the primary providers being critical care cardiologists. There was an absolute decrease in mortality of nearly 5% between the 2 time periods with an adjusted odds ratio of 0.43 (P<0.001). With the increasing complexity of CICU patients, it is possible that the majority of this benefit was derived from expertise in management of noncardiac complications as well as management of difficult cardiac cases requiring a combination of mechanical ventilator support, antimicrobial regimens, hemodynamic tailoring, and renal replacement therapies. Additionally, critical care cardiologists highlighted the importance of end-of-life care. Improved provider comfort with end-of-life care may foster timely goals-of-care discussions, which are associated with appropriate implementation of care limitations and withdrawal of life-sustaining therapies as well as lower healthcare costs. 18,19 These multiple areas are not sufficiently emphasized in general cardiology fellowships, and the majority of survey respondents agreed that a general cardiology fellowship alone is insufficient to manage patients effectively in the CICU. Looking forward, as the American Heart Association, American College of Cardiology, and corresponding international organizations move to set requirements for critical care cardiology training, it will be crucial to ensure that clinical competencies in a range of CCM skills are emphasized. 1,2,20 For example, the document published by the Core Cardiovascular Training Statement Task Force only designated intra-aortic balloon pump placement and endotracheal intubation as level III patient care milestones. 2 The skills outlined in this article may serve as a guide for proficiency standards in future iterations. This survey also provides additional experiential support for a CICU organizational shift to a collaborative, multidisciplinary care team structure, especially in hospitals with level I-and level II-type CICUs. 1 Although previously described as "closed" units, we believe this term to be imprecise and prefer the term collaboratively managed multidisciplinary units to more accurately reflect the situation in which there is a dedicated CICU attending trained in critical care who manages patients with input from the patient's primary, longitudinal provider.
Although not the primary intent of the survey, this study identified that only 3.3% of dual certified critical care cardiologists were women. This finding is in line with a previous investigation, which found that only 3.4% of physicians dual certified in CCM and CVD were female. 12 Interestingly, this gender gap far exceeds that of cardiology and critical care medicine in general, which only have 14.1% and 26.1% active women physicians, respectively. 21 A gender disparity of this magnitude is comparable with that of interventional cardiology and should trigger a call for cardiology leaders to better understand why so few women have chosen to pursue these specialties. 22 The issue is multifactorial, with potential contributors including compensation inequality and under-representation of women in leadership roles. 23,24 Improved mentorship for women considering critical care cardiology and ongoing diversity task force implementation will hopefully aide in closing the gender gap. 25

Study Limitations
The limitations of this study include its survey-based design with associated recall bias and a low response rate. The group of providers surveyed represent a highly specialized group with the potential for implicit bias in favor of their own training paradigm. Additionally, the majority of respondents completed their CCM training by the practice pathway, which is no longer an available avenue to CCM certification. Thus, the surveyed population may not accurately represent the attitudes of more recently graduated and future dual trained and certified critical care cardiologists. This is also potentially highlighted by the following dichotomy: The younger, CCM fellowship trained cardiologists reported working at university medical centers more than any other care setting, whereas the majority of practice pathway physicians reported working at nonacademic centers. This indicates that a higher proportion of practice pathway physicians may have transitioned into private practice. Lastly, although certification pathway was accounted for in nonresponse weighting adjustments, comparison between these two training groups was not predefined for stratified sampling.

Conclusion
Based on the clinical and professional experience of dual certified critical care cardiologists, CCM-acquired skills are likely a crucial component of patient care in the modern CICU. These areas should be emphasized in the development of integrated critical care cardiology training programs and highintensity CICU staffing models. Although formal CCM fellowship training may not be required for all providers, general cardiology fellowship programs should consider new curriculum and pathways to prepare trainees to provide optimal care in the modern CICU. Critical care training has long been standard in medical and surgical ICUs and has recently gained acceptance in neurological ICUs. Critical care cardiology training for the CICU should also be prioritized.