CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Michelle Gurvitz, MD*,
Ruey-Kang Chang, MD, MPH,
Fernando Ramos, BA,
Vivekanand Allada, MD,
John Child, MD and
Thomas Klitzner, MD, PhD
* Heart Center, W-4841, Children’s Hospital and Regional Medical Center, 4800 Sand Point Way, NE, Seattle, Washington 98105 (Email: michelle.gurvitz{at}seattlechildrens.org).
We appreciate the interest Dr. Driscoll expresses in our study (1). In his letter, Dr. Driscoll suggests that pediatric cardiologists are better equipped to treat adult congenital heart disease (CHD) patients because they are "inherently better trained" in the underlying diseases, and that they should "work in conjunction with the patient’s primary care internist, family practitioner, or internist cardiologist." There is no reasonable dispute with this premise as pediatric cardiologists often receive more training in the underlying diseases at issue. We respectfully disagree, however, with Dr. Driscoll’s conclusion that care for an emerging population of adult CHD patients should be committed solely, or primarily, to pediatric cardiologists.
Instead, several considerations favor the conclusion that adult and dual-boarded cardiologists should be properly trained to take an increasingly significant role in the care of adult CHD patients.
- 1 The numbers favor a greater and necessary role for adult cardiologists. As noted in our study, we estimate that the number of adult CHD patients is growing relatively quickly. Adult cardiologists in the U. S. outnumber pediatric cardiologists by a factor of 10 to 15 (1). A strategy that relies on pediatric cardiologists to treat new and existing pediatric patients as well as adult CHD patients will worsen the ratio of patients to cardiologists.
- 2 Adult CHD patients have other adult-onset medical issues. The CHD requires management in conjunction with acquired conditions of adulthood, including pregnancy, acquired heart disease, and other adult diseases such as diabetes and cancers. Adult cardiologists are better trained to deal with these acquired medical issues in which pediatric cardiologists have little or no training.
- 3 Practical difficulties accompany adult CHD inpatients. Children’s hospitals often cannot admit adult patients, and pediatric cardiologists may not be able to obtain admitting privileges at adult-care facilities.
Ultimately, the argument is not about which group should contribute more care for adult CHD patients. The question is how we can supply the needed care to this growing population given a potential provider shortage, coupled with shortages in training of most adult and pediatric cardiologists. As mentioned in our study, this care will currently need to be provided in a number of different combinations and arrangements. Our assessment is that pediatric cardiologists, adult cardiologists, congenital cardiac surgeons, and adult primary care physicians are, and must continue to be, excellent consultants to each other in the comprehensive care of adults with CHD. Dr. Driscoll’s observations regarding the significant contribution of pediatric cardiologists to the care of adults with CHD are both cogent and important. However, given the gap between supply of providers and demand for care, adult cardiologists should receive proper training so as to assume a larger role in the care of adult CHD patients.
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References
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- Gurvitz MZ, Chang RK, Ramos FJ, Allada V, Child JS, Klitzner TS. Variations in adult congenital heart disease training in adult and pediatric cardiology fellowship programs J Am Coll Cardiol 2005;46:893-898.[Abstract/Free Full Text]
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