Considering a Cardiometabolic Subspecialty The possibility of recognizing a distinct cardiometabolic subspecialty has been the subject of increasing discussion. We spoke with Robert H. Eckel, MD, a professor at the University of Colorado School of Medicine, Anschutz Medical Campus, to hear his thoughts on the subject. Medscape: Thanks for speaking with me, Dr Eckel. First off, what specifically would a cardiometabolic subspecialty entail? Eckel: I think this subspecialty would be driven both by scientific rationale and by clinical rationale in terms of the increasingly obese diabetic and aging population, where cardiovascular disease is very common. Check here: Free Medical Specialty Quiz The program that I envision is a 2-year internal medicine residency program, then a 4-year training program in metabolic diseases and cardiovascular disease prevention. I think internal medicine first, rather than family practice, because board specialization by the American Board of Internal Medicine would require an internal medicine specialty training before the subspecialty. The metabolic training would be in the areas of diabetes, lipid and lipoprotein disorders, obesity, and lifestyle (nutrition, physical activity), with the underpinning of genetics to rule out and expand the horizon that relates to these common metabolic diseases. Unlike the classic endocrinology training program, there would be no formal emphasis on pituitary, thyroid or adrenal disease, reproductive medicine, or metabolic bone disease. On the cardiology side, there would be no procedural training. These candidates would not have experiences in interventional cardiology, meaning no cardiac catheterization. They would not be involved in advanced heart failure or transplantation-related cardiology. There would be no electrophysiology, meaning training in cardiac arrhythmias and related therapeutics. Their training would be inpatient cardiology consults and inpatient coronary care unit experiences, managing acute myocardial infarction, acute coronary syndromes, and related complications. The trainee would also be schooled in electrocardiography and echocardiography. Hypertension training would cross over between metabolic diseases (a touch of endocrinology) and cardiology. Medscape: Given the crossover that already occurs, why the need for a separate subspecialty now? Eckel: Well, for example, I'm not sure cardiologists are ready to give glucagon-like peptide 1 (GLP1) receptor agonists or sodium-glucose cotransporter 2 (SGLT2) inhibitors to patients, despite the cardiovascular disease outcome trials that show benefit of these agents in patients with diabetes. And metabolic specialists are not in a position go beyond what they've learned as internists in interpreting and billing for ECGs and then echocardiograms. I think we're not going to optimally meet the cardiometabolic patient's need in the current setting. Perhaps "need" is too strong of a word, but I think this is an area that would be right for serious consideration of training people who are going to be overlapping their skill set in both metabolic diseases and cardiovascular disease. Issues related to cardiovascular disease come up in almost every visit in patients with diabetes. Preventing cardiovascular disease relates to lots of issues. It relates to risk factors, including metabolic issues. I think the Venn diagram between metabolic diseases, such as diabetes, and heart disease has closed increasingly over time. I think that's why it's timely right now. Having doctors explicitly trained in this crossover between these two medical subspecialties really makes a lot of sense. And there's got to be momentum. I've begun conversations with people at the American College of Cardiology, the American Diabetes Association, and soon with the American Heart Association, where I had the privilege of serving as president a decade ago. I have not formally presented this concept yet, but I don't think there would be any resistance. The question is, what you do with such organizations as the Obesity Society and the National Lipid Association in terms of bringing them into the fold? I think this is an area where many people within these groups would be very interested, and have historically been very interested in getting this type of concentrated and formalized training. Medscape: What would you say to a critic who might dispute the need for another specialty? Eckel: That's a good question. Most people who go into cardiology want to be more invasive in terms of skill set. One of the skepticisms could be that [potential cardiometabolic subspecialists] could just do clinical cardiology instead and be a preventive cardiologist. That would be one area of skepticism. The argument on the other side is why a sophisticated diabetologist or an obesity/lipid-related physician needs to be further trained in ECGs and trained at all in echocardiography. Even though there would be arguments to say people could take their own training program and direct themselves to this area, there is no such desire in endocrinologists. I think the training is going to be subpar to adequately cover both benches. Medscape: Which medical students do you think would be the ones most interested in this subspecialty, and what would your selling point be for why they should consider it? Eckel: Most medical students don't get enamored by medical "zebras" or rare diseases. In other words, you don't hear "I just want to study congenital ventricular diverticula!" That's not something that blossoms during the second or third year of medical school, a time when decisions about the future begin to be clarified. Obesity is common. Diabetes is common. High cholesterol is common, and cardiovascular disease causes 35%-40% of all deaths. That's the appeal, I think—appealing to common diseases where you can make a difference in a large number of people with ongoing clinical care and related research. Medscape: What's next in terms of the movement to recognize a cardiometabolic subspecialty? Eckel: There's work to do to create a document that would really rationalize the need for this subspecialty training. I'm sure the American Board of Internal Medicine feels like the number of subspecializations is replete and another one doesn't really need further consideration. But I think there are a number of us in the cardiometabolic space who feel differently. There is momentum here that has been created and is growing globally. I've been pretty outward about my thoughts about this for some time, and just recently have been discussing this openly with many colleagues in the field. However, more needs to be done. There's a whole platform of people on both sides of this subspecialty view that may be willing to join the momentum and sign on to a document once created. Then, at that point, we need to adjoin with all relevant professional organizations. Source
