August 22, 2025 • 30 mins
This week we review a recent work addressing the growing mismatch between the numbers of ACHD patients and the numbers of well trained ACHD providers. What are the most important factors influencing trainees' decisions regarding the pursuit of a career in ACHD? How can more young people be influenced to pursue this fascinating and growing field? We speak with Dr. Katia Bravo-Jaimes of The Mayo Clinic in Jacksonville, FLA about a recent survey study she conducted on the factors that influenced these important decisions. Dr. Bravo-Jaimes shares her thoughts on solutions to increase the ACHD workforce.
https://doi.org/10.1161/jaha.125.041276
https://doi.org/10.1161/jaha.125.041276
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:16):
Welcome to Pedheart Pediatric Cardiology today. My name is doctor
Robert Pass and.
Speaker 2 (00:20):
I'm the host of this podcast.
Speaker 1 (00:22):
Thank you for joining me for this three hundred and
fifty second episode of Pdheart. Last week we reviewed a
prior episode on the topic of the impact of race
on outcomes of pediatric heart transplantation in the United States.
For those of you interested in this important topic, i'd
recommend you to take to listen to doctor Nahabansel on
our last episode last week. As I say most weeks,
(00:43):
if you'd like to get in touch with me, my
email is easy to remember. It's Pdheart at gmail dot com.
This week we move into an important area, adult congeneral
heart disease. The title of the work we'll be reviewing
is Adult Congenital Heart Disease as a Career Examining, encouraging
and deterring factors in the Global ADHD Survey. The first
(01:04):
author of this work is Katzia bravo Heims and the
senior author Jonathan Wyndham. And this work comes to us
from multiple centers throughout the world. Doctor Bravochims comes to
us from the Mayo Clinic in Jacksonville, Florida. When we're
done reviewing this paper, doctor Bravochims has graciously agreed to
speak with us about it. Therefore, let's get straight onto
this interesting survey study and then a conversation with its
(01:27):
first author. The work begins with some comments about what
we all increasingly are aware of, which is the large
and growing numbers of AHD patients in the world, and
that oft quoted fact that in two thousand and five,
for the first time in human history, there were more
adult congenital heart patients than children on planet Earth. Despite
these larger and larger numbers of patients, there are in
(01:49):
fact four times as many pediatric than adult congeneral heart specialists,
and the authors bemoan the potential impact of this patient
to provider mismatch may have. Studies have shown that ADHD
patients that are cared for by non ADHD specialists are
more likely to have no follow up and ends up
with more unexpected or unintended interventions than those who are
(02:11):
under true specialized ADHD care. The authors then review how
forty four percent of ADHD fellowship positions have gone unfilled
in the United States over the past four years, and
they mention also how twenty four percent of ADHD team
members in the UK have left due to financial considerations.
They also mention how these mismatches between patient numbers and
(02:34):
providers are similarly an issue in Africa, Latin America and
the Caribbean. With these somewhat depressing stats as a background,
the authors earnestly sought to figure out what the causes
of disinterest in becoming ACHD practitioners were by assessing the
factors that influenced cardiologist career choices away from or towards
ADHD and the author's words quote. This global survey sought
(02:58):
to describe the encouraging and determ factors influencing adult and
pediatric cardiologists in trainee's decision to pursue a career in ADHD,
and to identify possible solutions to overcome this shortage in
each specific region. The authors proceeded with an online anonymous
global survey on demographics ADHD as a career choice, asking
(03:20):
many questions regarding what encouraged or deterred cardiologists from entering
the field, and the authors used only surveys where respondents
answered at least seventy five percent of the questions that
were asked. Responses were recorded between November of twenty twenty
three and April of twenty twenty four, and the respondents
were grouped into either ADHD cardiologists with and without formal
(03:42):
training and non ACHD cardiologists, and they were characterized also
by region of practice to analyze geographic variations and dawn.
So the results. There were nine hundred and seventy one
recipients of the survey, of which one hundred and sixty
did not answer at least seventy five percent of the questions,
and so these were excluded, yielding a sample of eight
(04:03):
hundred and eleven respondents who answered. Fifty three percent of
the respondents were women, and forty eight percent or most
were between the ages of thirty one and forty years,
followed by twenty three percent who were between forty one
and fifty years old. Forty three percent of respondents were white,
twenty six percent Asian, fifteen percent Hispanic, twelve percent black,
(04:23):
and two point eight percent multiracial. Participants included adult cardiologists
constituting twenty four percent of the group, cardiovascar disease trainees,
who were twenty percent pediatric cardiologists at seventeen percent formally
trained ADHD doctors constituting sixteen percent, followed by pediatric cardiology
trainees eleven percent, Cardiologists with other specialties were eight and
(04:46):
a half percent, and ADHD cardiologists who did not have
formal training constituted five percent of the respondents. The majority
of these respondents were from North America forty three percent,
followed by Central and South America eight eighteen percent, then
Europe seventeen percent, Asia sixteen percent, Africa five percent, in
Oceania one percent. Only thirty one percent of non ADHD
(05:11):
doctors considered specializing in ADHD, despite seventy nine percent receiving
some recommendations of it as a specialty during their training.
And what did respondents view as factors that encouraged the
pursuit of ADHD as a career. These were awareness of ADHD,
the influence of a mentor, and finally clinical exposure. In
(05:33):
similar vein, what factors were deterrents to becoming an ADHD
doctor In these surveys, While these included inadequate financial incentives,
limited job opportunities, and finally the length of training and
what about solutions? The most common recommendation was the creation
of structured and accredited training programs. Following this recommendation, the
(05:54):
respondents commented on the need for improved salary and job availability.
They also emphasized the important role that early exposure to
adult congeneral heart disease had to their career choice, and
believed that early exposure in medical school or training could
spark early interest. The respondents also mentioned the importance of
integrating an ADHD curriculum into residency and fellowship training, and
(06:18):
they mentioned the importance of ADHD mentors in their discussion.
The author's state and I quote. This study offers a
valuable perspective on the factors influencing cardiologists decisions to pursue
a career in ADHD, Filling a crucial gap in our
understanding of workforce shortages in this field. Identifying the motivations, challenges,
(06:38):
and regional disparities sheds light on the key contributors to
the shortage of specialized adult congeneral heart disease cardiologists in
different parts of the world. As the first comprehensive multi
center survey of its kind, the findings provide actionable insights
for improving recruitment strategies, enhancing training opportunities, and promoting a
(06:58):
greater interest in AID as a career path. The author's
contrast how compensation and work life balance were significant to
terrence for advanced heart failure and transplant cardiology careers in
prior studies, but this study showed that patient complexity and
long term relationships, which were frowned upon by those in
that field, were viewed positively by ACHD doctors. The authors
(07:22):
speak about the absence of formal training outside the United
States and in many areas of the globe, and they
offer examples such as in Oceania or Latin America where
there is either limited training or inconsistent training. The authors
also point to limitations and funding for fellowships. They mentioned
that though the establishment of training programs is thought to
(07:42):
increase the number of practitioners, in truth a large number
of fellowship positions remain unfilled, suggesting that just offering more
opportunities for training is not enough. They speak about possibly
shortening the training or streamlining it, suggesting possibly short term
certification programs for general or pediatric cardiologists. They mention increasing
(08:04):
medical school attention or exposure to adult congeneral heart disease
during residency as well to spark interest. They speak about
the fact that the payment for non procedural fields like
adult congeneral heart disease are lower than procedural specialties, and
how reimbursement models favor large volumes of procedures. Add to
this fact that adult congeneral heart disease centers are usually
(08:26):
associated with academic programs, and the reimbursement or compensation to
the adult congeneral heart disease provider is going to be
lower and many more lucrative areas within cardiology, this is
a very difficult barrier to manage given the substantial debt
levels that doctors often take on going to medical school.
They end the papers speaking of the limitations of a
voluntary survey study and the selection bias that this can introduce.
(08:50):
They also mention the possible lack of generalizability to all
regions because participation from some regions were very limited, and
so they conclude, despite significant interest in adult congel heart disease,
less than a third of responders considered adult congel heart
disease as a career due to deterrence such as inadequate
financial incentives, limited job opportunities, and extensive training duration, which
(09:14):
jeopardizes quality of care and continuity for the growing adult
congel heart disease population. Although expanding structured training programs is essential,
their success depends heavily on addressing systemic barriers such as
financial disincentives and career instability. Alternative strategies including integrating interdisciplinary education,
(09:36):
offering short term certification programs, leveraging telemedicine based mentorship, and
enhancing financial incentives could effectively boost recruitment. Ultimately, collaboration among institutions, societies,
and policy makers is needed to ensure a well distributed,
adequately trained workforce to meet rising global demands. While this
(09:58):
is clearly a major problem that the use authors are
attempting to tackle in this work, we have on more
than one occasion spoken of the growing tsunami of ADHD
patients that are coming our way and how the workforce
is not adequate to address the needs of this complex
group of patients who have so many different needs. This
work is important and that it is trying to figure
(10:18):
out why people don't want to pursue this field and
how to change that. In the interest of time, I
think I'll move forward to my conversation with the work's
first author, doctor Bravo Reims to get her thoughts on
this topic and her ideas regarding addressing this very important problem.
Joining us now to discuss this week's work is the
work's first author, doctor Katia Bravo Reimes. Doctor Bravochimes attended
(10:41):
medical school in Lima, Peru, and completed her internal medicine
residency at the University of Rochester in New York, followed
by cardiovascular fellowship at the University of Texas Health Center
at Houston and eventually Adult Congeneral Heart Disease Fellowship at
the University of California and Los Angeles. She's a prior
guest to the podcast and it is aslike to have
her to this week on the podcast to discuss this
(11:01):
important work. Welcome, doctor Bravohaimez to PDHRT. I'm here now
with doctor Katia Bravo Chaimes from the Mayo Clinic out
in Florida. Doctor Bravochaimes, thank you very much for joining
us this week on PDHART.
Speaker 3 (11:13):
Thank you doctor Paz for having me here. I'm excited
to discuss the results of this global ADHD survey.
Speaker 2 (11:20):
Yeah, very interesting work.
Speaker 1 (11:22):
Indeed, you know, doctor Bravohaimes, your study found that insufficient
financial incentives limited job opportunities as well as a long
training period, where three of the most common offered reasons
for people who didn't want to pursue ADHD. I'm wondering,
as a practicing ADHD doctor, if you have any insights
(11:43):
into which of these are likely the most important to
trainees and why.
Speaker 2 (11:47):
Thank you for the question.
Speaker 3 (11:49):
We have looked into the original data according to type
of trainees, and we know that among the cardiology trainees
the adult cardiology trainees, the lack of compensation incentive and
the limited job opportunities are the two main factors. The
third one was the length of training. There's a perception
(12:10):
in general that the return on investment is significantly higher
when pursuing procedural specialties such as electrophysiology or international cardology
compared to clinical specialty like ADHD, and there's also a
difference in the duration of fellowships. Interventional cardiology only takes
one year, whereas EP and ADHD take two years. But
(12:35):
in addition to these two factors, the perception is also
that you can only practice ADHD at a large academic
center and the compensation is significantly lower compared to the
other two specialties mentioned In regards to pediatric cardology trainees.
We have seen that the main factors are the length
(12:56):
of training. That's number one. The second one was concerns
about emotional and psychological challenges associated with ACHD care, and
the third one was the lack of compensation incentive. And
here I think that the length of training is something
much more significant for the pediatric cardology trainees. Because international
(13:18):
pediatric cardiology is of one year. EP could be also
one year. There are programs that offer it for eighteen
months and ECH these two years. So definitely ACHD has
disadvantage in this case in terms of the concern about
emotional and psychological challenges. I think many of the pediatric
(13:40):
cardiologists love to see children. That's a very significant difference
when you compared to ADHD. And there may be much
more complexities into taking care of the adults with congender
heart disease who may have other needs in terms of
mental health needs, which puts them in a different category
(14:03):
than the children that they usually take care of.
Speaker 1 (14:06):
Yeah, that's all very good points and really is true.
It's quite different, isn't it. And I've often wondered if
the training period should be adjusted depending from which route
you're coming at adult congenital heart disease, whether from the
adult world or pediatric.
Speaker 2 (14:23):
You know, doctor barbohaimes.
Speaker 1 (14:25):
Many of the listeners of this podcast are pediatric cardiologists
and are not as familiar with the salary structures of
adult cardiologists in the United States. Just as a point
of reference for those of us not as familiar. How
much different is the compensation for an ADHD doctor versus
that of say, a general academic cardiologist, just on a
(14:45):
percentage basis, I mean, how much more does the lack
of a better term, regular adult cardiologists typically make even
without additional training. I mean, is this And I was
wondering if this difference in compensation is also observed outside
of the United States.
Speaker 3 (15:01):
Yeah. I think there's some data from a manuscript from
twenty nineteen by doctors Ephraim and al Shawaki that was
publishing an international Journal of Cardology where they surveyed EZHDA physicians,
approximately thirty of them. And this was back in twenty seventeen,
so there's a little bit of difference with the current salaries.
(15:23):
And the ADHD salaries were on average five percent higher
than the pediatric cardiology salaries and twenty seven percent lower
than an academic, non invasive adult cardologist. This has to
be taken with a grain of salt because newer data
suggests that, yes, the gaps in between pediatric cardology and
(15:47):
adult cardology are still in place, but maybe wider if
we take into account the whole pool of cardiologists, both
who practice in academic and private settings. And this was
demonstrated in an an article in twenty twenty four by
doctor Chaudhry and doctor ROBERTA. Williams, and they mentioned that
(16:11):
the difference was quite quite significant. Approximately, the pedi cardiology
salaries represented seventy two percent of the adult cardiology salary,
so a twenty eight percent gap.
Speaker 1 (16:28):
Wow.
Speaker 2 (16:28):
Wow, very interesting.
Speaker 1 (16:30):
I'm sure many of my colleagues in pediatric cardiology are
bemoaning the fact that they chose not to become adult cardiologists.
Based on some of the information you just shared, you know,
it seems like from your study, having an experience an
adult congeneral heart disease or congeneral heart disease in general,
was highly associated with the pursuit of the field, and
(16:52):
that a much lower percentage of non ADHD adult cardiologists
who chose to not pursue it had an actual ADHD
experience in training, suggesting that this type of exposure to
congenital heart disease is helpful in encouraging some practitioners to
pursue the field. I'm wondering knowing this, and I think
(17:12):
a lot of you in your field know this already.
What is happening in adult medicine and cardiology to increase
this exposure to the internal medicine residents and general categorical
cardiology fellows to maybe stir up a little more interest.
Speaker 3 (17:27):
Yes, I think many of the ADHD programs have incorporated
ADHD rotations during General Cardology fellowship. We often see this
rotation introducing the third year of fellowship, but at this
point many of the fellows have already decided on a
career path, so having it early, like in the second year,
it would be much more ideal because they still need
(17:49):
some foundational imaging skills to be able to rotate in ADHD.
In the internal medicine residence, I think that there's a
lot of opportunity including mentorship with an ACHD physician, clinical
exposure with rotations, or taking care of ACHD patients in
(18:09):
the carreology service or in the CCU as well as
educational opportunities, and here I wanted to highlight the global
conversations in ADHD webinar series where we engage twenty five
residents and cardology trainees across six countries to present and
lead case based discussions in ADHD. We have an upcoming
(18:34):
proposal where we're going to publish the results where we
engage approximately eighty six countries and over two thousand registrations
across the globe.
Speaker 2 (18:45):
Wow, very interesting, congratulations on that.
Speaker 1 (18:49):
You know, the thing that kept coming back to me
was the lack of jobs and adult continer heart disease,
which seemed to be an important reason that people choose
not to pursue it. But wondering, how do you square
the fact that there are too few positions with the
gigantic number of patients that exist. I mean, what other
(19:09):
reasons that the number of positions don't match the needs?
I mean, not only do they not match the needs,
but you're basically explaining that hospitals don't even have to
pay these doctors as much money. And yet still there
seems to be a very large mismatch between the need
and the actual delivery care deliverers.
Speaker 3 (19:29):
Yes, I think that there are multiple factors here. Whereas
there are several hundred jobs in general cardiology across private
and academic centers with broad geographic variety, in ECHD, we
only have a few teams, mostly in academic centers at
medium to large cities. But having said this, they're up
(19:51):
to twenty four graduates per year and job security is warranteed.
There's also a high job satisfaction. Of the recent graduates
report that their job represents their ideal or near their
ideal job. The patients also may not be transitioning full
(20:13):
from pediatric to adult congenital care. Other patients are lost
to care due to the social determinants of health and
maybe also really sparse in terms of their geographic location,
and that makes it harder to centralize these services. There's
also a lot of patients who are still able to
(20:36):
only access general cardiology care locally, and the article by
Kayla Lopez had demonstrated that the greatest majority of the
US population is generally more than one hour away from
an ACHD center, So that puts in context that despite
(20:56):
the volume of patients may be large, they might be
very unequally distributed, and some of them may not be
able to access the right care because of the social
determinants of health.
Speaker 1 (21:08):
That really highlights the importance of transition that Kayla is
so strongly supportive of.
Speaker 2 (21:15):
Well for those in the audience, We're.
Speaker 1 (21:16):
Coming to the end of the week and the end
of the day, and doctor Bravo Cheimis was nice enough
to give us time at the time of the week
where we all know we get a million phone calls.
Speaker 2 (21:25):
I'm sure you're very busy, so I'll finish it up here.
You know.
Speaker 1 (21:28):
The respondents to your survey offered their own thoughts on
how to enhance interest in the pursuit of adult congeneral
heart disease amongst trainees. As a very experienced, busy adult
congeneral heart practitioner, I'm wondering, what do you think should
be the central components of a strategy to increase the
ADHD workforce and interest among young people who are trainees.
Speaker 3 (21:52):
I think that spark in the firing ADHD takes a village.
I have reflected a lot on my personal history, and
I can say that this field is for those who
see the patient as a whole, as a whole human
with complexities inside and outside the heart. And for people
who love solving problems thinking outside the box. Early exposure
(22:14):
is key and we need to increase awareness about this
field engaging the trainees in community activities such as pediatric
heart camps for example. They don't need to know all
the ACHD complexities to participate here. They can be volunteers.
They can also participate in global health experiences, clinical rotations,
(22:36):
and also engage them in educational activities such as the
global conversations in ADHD that I mentioned. Finally, research experience
are also important to keep the fire burning because many
of the internal medicine residents are looking for that interesting
case to publish, and what a better case than in ADHD.
(22:57):
I would say mentorship, but it is also fundamental and
here I wanted to pay tribute to doctor Latta Larde
who saw something in me back in Perule when I
was a medical student and created a pipeline program to
train in the US. Also to doctor James twelve with
whom I had my first pediatric carriology rotation and congenital
(23:19):
heart surgery exposure during his time in Milwaukee, Doctor Putong
who demonstrated that a strong image and foundation opens the
door to ADHD and finally to doctor Jami labl Whosong,
who's extreme ownership demonstrated what it takes to be in
a leader in ADHD.
Speaker 1 (23:37):
Wow, those are some powerful names you just mentioned. I
guess it's no surprise what you yourself are becoming a leader
within the field. So, doctor Bravochheimes, I really appreciate you
joining us this week again on the podcast highlighting what
is a very big problem that I often refer to
it as the tsunami of patients that are coming towards us,
(23:58):
and so it definitely takes the village to take care
of these patients, and I'm learning to encourage people to
become part of the team that does that. I want
to thank you and congratulate you and your co authors
on this very important survey study.
Speaker 2 (24:11):
Thank you very much, Thank you pass again.
Speaker 1 (24:14):
Well, much as before, doctor Bravo Jaimes really well summarized
her work and the scope of this important problem. I
thought her comments about the sort of person who would
do well in this field to be of great importance.
As she spoke, I realized that one really needs to
be a complete doctor like our transplant colleagues or perhaps
oncology physicians, because these patients have so many different challenges,
(24:38):
and this notion really resonated with me as I thought
about the three adult congenital heart specialists that I work
with every day, doctor Ali Zaidi, Doctor Kaylee Hopkins, and
doctor Barry Love, who are each really complete doctors who
work hard to address the many problems that a number
of our ADHD patients face. This is not an easy task,
(24:59):
but when done right, it is clearly life changing and
maybe even life saving. Off air, doctor Bravochaimes explained that
there are some programs that are trialing two plus two training,
whereby the Internal Medicine Cardiology fellow can start the two
years of ADHD training in what would normally be year
three of categorical fellowship. This is apparently an experiment that's starting,
(25:21):
and I'm sure we'll learn more about how it's working out.
Given the clarity of her thought, I think there's not
much more for me to add of. That's once again
thank doctor Bravochaimes for her time this week on Pedihart.
To conclude this three hundred and fifty second episode of
Pedihard Pediatric Cardiology, today we hear the wonderful Spanish tenor
Jose Carreras singing the heartbreaking aria to kea dio Spiegasti
(25:46):
from the last act of Luccia di Lamomoor by Donizetti.
This is a live performance from nineteen eighty one, shortly
before Carreras developed leukemia, which he famously defeated after a
home mare transplant at the Fred Hutchinson Cancer Center in
the late nineteen eighties. Here how wonderfully his voice carries
(26:06):
throughout the hall with a beautiful tone. Thank you very
much for joining me for this three hundred and fifty
second episode, and thanks once again to doctor Bravo himis
I hope I'll have a good week.
Speaker 4 (26:17):
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Lovel a, say.
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My turn.
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Got there in time?
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On my enma.
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The lo re normal wan to g wing t mo.
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Welcome to Pedheart Pediatric Cardiology today. My name is doctor
Robert Pass and.
Speaker 2 (00:20):
I'm the host of this podcast.
Speaker 1 (00:22):
Thank you for joining me for this three hundred and
fifty second episode of Pdheart. Last week we reviewed a
prior episode on the topic of the impact of race
on outcomes of pediatric heart transplantation in the United States.
For those of you interested in this important topic, i'd
recommend you to take to listen to doctor Nahabansel on
our last episode last week. As I say most weeks,
(00:43):
if you'd like to get in touch with me, my
email is easy to remember. It's Pdheart at gmail dot com.
This week we move into an important area, adult congeneral
heart disease. The title of the work we'll be reviewing
is Adult Congenital Heart Disease as a Career Examining, encouraging
and deterring factors in the Global ADHD Survey. The first
(01:04):
author of this work is Katzia bravo Heims and the
senior author Jonathan Wyndham. And this work comes to us
from multiple centers throughout the world. Doctor Bravochims comes to
us from the Mayo Clinic in Jacksonville, Florida. When we're
done reviewing this paper, doctor Bravochims has graciously agreed to
speak with us about it. Therefore, let's get straight onto
this interesting survey study and then a conversation with its
(01:27):
first author. The work begins with some comments about what
we all increasingly are aware of, which is the large
and growing numbers of AHD patients in the world, and
that oft quoted fact that in two thousand and five,
for the first time in human history, there were more
adult congenital heart patients than children on planet Earth. Despite
these larger and larger numbers of patients, there are in
(01:49):
fact four times as many pediatric than adult congeneral heart specialists,
and the authors bemoan the potential impact of this patient
to provider mismatch may have. Studies have shown that ADHD
patients that are cared for by non ADHD specialists are
more likely to have no follow up and ends up
with more unexpected or unintended interventions than those who are
(02:11):
under true specialized ADHD care. The authors then review how
forty four percent of ADHD fellowship positions have gone unfilled
in the United States over the past four years, and
they mention also how twenty four percent of ADHD team
members in the UK have left due to financial considerations.
They also mention how these mismatches between patient numbers and
(02:34):
providers are similarly an issue in Africa, Latin America and
the Caribbean. With these somewhat depressing stats as a background,
the authors earnestly sought to figure out what the causes
of disinterest in becoming ACHD practitioners were by assessing the
factors that influenced cardiologist career choices away from or towards
ADHD and the author's words quote. This global survey sought
(02:58):
to describe the encouraging and determ factors influencing adult and
pediatric cardiologists in trainee's decision to pursue a career in ADHD,
and to identify possible solutions to overcome this shortage in
each specific region. The authors proceeded with an online anonymous
global survey on demographics ADHD as a career choice, asking
(03:20):
many questions regarding what encouraged or deterred cardiologists from entering
the field, and the authors used only surveys where respondents
answered at least seventy five percent of the questions that
were asked. Responses were recorded between November of twenty twenty
three and April of twenty twenty four, and the respondents
were grouped into either ADHD cardiologists with and without formal
(03:42):
training and non ACHD cardiologists, and they were characterized also
by region of practice to analyze geographic variations and dawn.
So the results. There were nine hundred and seventy one
recipients of the survey, of which one hundred and sixty
did not answer at least seventy five percent of the questions,
and so these were excluded, yielding a sample of eight
(04:03):
hundred and eleven respondents who answered. Fifty three percent of
the respondents were women, and forty eight percent or most
were between the ages of thirty one and forty years,
followed by twenty three percent who were between forty one
and fifty years old. Forty three percent of respondents were white,
twenty six percent Asian, fifteen percent Hispanic, twelve percent black,
(04:23):
and two point eight percent multiracial. Participants included adult cardiologists
constituting twenty four percent of the group, cardiovascar disease trainees,
who were twenty percent pediatric cardiologists at seventeen percent formally
trained ADHD doctors constituting sixteen percent, followed by pediatric cardiology
trainees eleven percent, Cardiologists with other specialties were eight and
(04:46):
a half percent, and ADHD cardiologists who did not have
formal training constituted five percent of the respondents. The majority
of these respondents were from North America forty three percent,
followed by Central and South America eight eighteen percent, then
Europe seventeen percent, Asia sixteen percent, Africa five percent, in
Oceania one percent. Only thirty one percent of non ADHD
(05:11):
doctors considered specializing in ADHD, despite seventy nine percent receiving
some recommendations of it as a specialty during their training.
And what did respondents view as factors that encouraged the
pursuit of ADHD as a career. These were awareness of ADHD,
the influence of a mentor, and finally clinical exposure. In
(05:33):
similar vein, what factors were deterrents to becoming an ADHD
doctor In these surveys, While these included inadequate financial incentives,
limited job opportunities, and finally the length of training and
what about solutions? The most common recommendation was the creation
of structured and accredited training programs. Following this recommendation, the
(05:54):
respondents commented on the need for improved salary and job availability.
They also emphasized the important role that early exposure to
adult congeneral heart disease had to their career choice, and
believed that early exposure in medical school or training could
spark early interest. The respondents also mentioned the importance of
integrating an ADHD curriculum into residency and fellowship training, and
(06:18):
they mentioned the importance of ADHD mentors in their discussion.
The author's state and I quote. This study offers a
valuable perspective on the factors influencing cardiologists decisions to pursue
a career in ADHD, Filling a crucial gap in our
understanding of workforce shortages in this field. Identifying the motivations, challenges,
(06:38):
and regional disparities sheds light on the key contributors to
the shortage of specialized adult congeneral heart disease cardiologists in
different parts of the world. As the first comprehensive multi
center survey of its kind, the findings provide actionable insights
for improving recruitment strategies, enhancing training opportunities, and promoting a
(06:58):
greater interest in AID as a career path. The author's
contrast how compensation and work life balance were significant to
terrence for advanced heart failure and transplant cardiology careers in
prior studies, but this study showed that patient complexity and
long term relationships, which were frowned upon by those in
that field, were viewed positively by ACHD doctors. The authors
(07:22):
speak about the absence of formal training outside the United
States and in many areas of the globe, and they
offer examples such as in Oceania or Latin America where
there is either limited training or inconsistent training. The authors
also point to limitations and funding for fellowships. They mentioned
that though the establishment of training programs is thought to
(07:42):
increase the number of practitioners, in truth a large number
of fellowship positions remain unfilled, suggesting that just offering more
opportunities for training is not enough. They speak about possibly
shortening the training or streamlining it, suggesting possibly short term
certification programs for general or pediatric cardiologists. They mention increasing
(08:04):
medical school attention or exposure to adult congeneral heart disease
during residency as well to spark interest. They speak about
the fact that the payment for non procedural fields like
adult congeneral heart disease are lower than procedural specialties, and
how reimbursement models favor large volumes of procedures. Add to
this fact that adult congeneral heart disease centers are usually
(08:26):
associated with academic programs, and the reimbursement or compensation to
the adult congeneral heart disease provider is going to be
lower and many more lucrative areas within cardiology, this is
a very difficult barrier to manage given the substantial debt
levels that doctors often take on going to medical school.
They end the papers speaking of the limitations of a
voluntary survey study and the selection bias that this can introduce.
(08:50):
They also mention the possible lack of generalizability to all
regions because participation from some regions were very limited, and
so they conclude, despite significant interest in adult congel heart disease,
less than a third of responders considered adult congel heart
disease as a career due to deterrence such as inadequate
financial incentives, limited job opportunities, and extensive training duration, which
(09:14):
jeopardizes quality of care and continuity for the growing adult
congel heart disease population. Although expanding structured training programs is essential,
their success depends heavily on addressing systemic barriers such as
financial disincentives and career instability. Alternative strategies including integrating interdisciplinary education,
(09:36):
offering short term certification programs, leveraging telemedicine based mentorship, and
enhancing financial incentives could effectively boost recruitment. Ultimately, collaboration among institutions, societies,
and policy makers is needed to ensure a well distributed,
adequately trained workforce to meet rising global demands. While this
(09:58):
is clearly a major problem that the use authors are
attempting to tackle in this work, we have on more
than one occasion spoken of the growing tsunami of ADHD
patients that are coming our way and how the workforce
is not adequate to address the needs of this complex
group of patients who have so many different needs. This
work is important and that it is trying to figure
(10:18):
out why people don't want to pursue this field and
how to change that. In the interest of time, I
think I'll move forward to my conversation with the work's
first author, doctor Bravo Reims to get her thoughts on
this topic and her ideas regarding addressing this very important problem.
Joining us now to discuss this week's work is the
work's first author, doctor Katia Bravo Reimes. Doctor Bravochimes attended
(10:41):
medical school in Lima, Peru, and completed her internal medicine
residency at the University of Rochester in New York, followed
by cardiovascular fellowship at the University of Texas Health Center
at Houston and eventually Adult Congeneral Heart Disease Fellowship at
the University of California and Los Angeles. She's a prior
guest to the podcast and it is aslike to have
her to this week on the podcast to discuss this
(11:01):
important work. Welcome, doctor Bravohaimez to PDHRT. I'm here now
with doctor Katia Bravo Chaimes from the Mayo Clinic out
in Florida. Doctor Bravochaimes, thank you very much for joining
us this week on PDHART.
Speaker 3 (11:13):
Thank you doctor Paz for having me here. I'm excited
to discuss the results of this global ADHD survey.
Speaker 2 (11:20):
Yeah, very interesting work.
Speaker 1 (11:22):
Indeed, you know, doctor Bravohaimes, your study found that insufficient
financial incentives limited job opportunities as well as a long
training period, where three of the most common offered reasons
for people who didn't want to pursue ADHD. I'm wondering,
as a practicing ADHD doctor, if you have any insights
(11:43):
into which of these are likely the most important to
trainees and why.
Speaker 2 (11:47):
Thank you for the question.
Speaker 3 (11:49):
We have looked into the original data according to type
of trainees, and we know that among the cardiology trainees
the adult cardiology trainees, the lack of compensation incentive and
the limited job opportunities are the two main factors. The
third one was the length of training. There's a perception
(12:10):
in general that the return on investment is significantly higher
when pursuing procedural specialties such as electrophysiology or international cardology
compared to clinical specialty like ADHD, and there's also a
difference in the duration of fellowships. Interventional cardiology only takes
one year, whereas EP and ADHD take two years. But
(12:35):
in addition to these two factors, the perception is also
that you can only practice ADHD at a large academic
center and the compensation is significantly lower compared to the
other two specialties mentioned In regards to pediatric cardology trainees.
We have seen that the main factors are the length
(12:56):
of training. That's number one. The second one was concerns
about emotional and psychological challenges associated with ACHD care, and
the third one was the lack of compensation incentive. And
here I think that the length of training is something
much more significant for the pediatric cardology trainees. Because international
(13:18):
pediatric cardiology is of one year. EP could be also
one year. There are programs that offer it for eighteen
months and ECH these two years. So definitely ACHD has
disadvantage in this case in terms of the concern about
emotional and psychological challenges. I think many of the pediatric
(13:40):
cardiologists love to see children. That's a very significant difference
when you compared to ADHD. And there may be much
more complexities into taking care of the adults with congender
heart disease who may have other needs in terms of
mental health needs, which puts them in a different category
(14:03):
than the children that they usually take care of.
Speaker 1 (14:06):
Yeah, that's all very good points and really is true.
It's quite different, isn't it. And I've often wondered if
the training period should be adjusted depending from which route
you're coming at adult congenital heart disease, whether from the
adult world or pediatric.
Speaker 2 (14:23):
You know, doctor barbohaimes.
Speaker 1 (14:25):
Many of the listeners of this podcast are pediatric cardiologists
and are not as familiar with the salary structures of
adult cardiologists in the United States. Just as a point
of reference for those of us not as familiar. How
much different is the compensation for an ADHD doctor versus
that of say, a general academic cardiologist, just on a
(14:45):
percentage basis, I mean, how much more does the lack
of a better term, regular adult cardiologists typically make even
without additional training. I mean, is this And I was
wondering if this difference in compensation is also observed outside
of the United States.
Speaker 3 (15:01):
Yeah. I think there's some data from a manuscript from
twenty nineteen by doctors Ephraim and al Shawaki that was
publishing an international Journal of Cardology where they surveyed EZHDA physicians,
approximately thirty of them. And this was back in twenty seventeen,
so there's a little bit of difference with the current salaries.
(15:23):
And the ADHD salaries were on average five percent higher
than the pediatric cardiology salaries and twenty seven percent lower
than an academic, non invasive adult cardologist. This has to
be taken with a grain of salt because newer data
suggests that, yes, the gaps in between pediatric cardology and
(15:47):
adult cardology are still in place, but maybe wider if
we take into account the whole pool of cardiologists, both
who practice in academic and private settings. And this was
demonstrated in an an article in twenty twenty four by
doctor Chaudhry and doctor ROBERTA. Williams, and they mentioned that
(16:11):
the difference was quite quite significant. Approximately, the pedi cardiology
salaries represented seventy two percent of the adult cardiology salary,
so a twenty eight percent gap.
Speaker 1 (16:28):
Wow.
Speaker 2 (16:28):
Wow, very interesting.
Speaker 1 (16:30):
I'm sure many of my colleagues in pediatric cardiology are
bemoaning the fact that they chose not to become adult cardiologists.
Based on some of the information you just shared, you know,
it seems like from your study, having an experience an
adult congeneral heart disease or congeneral heart disease in general,
was highly associated with the pursuit of the field, and
(16:52):
that a much lower percentage of non ADHD adult cardiologists
who chose to not pursue it had an actual ADHD
experience in training, suggesting that this type of exposure to
congenital heart disease is helpful in encouraging some practitioners to
pursue the field. I'm wondering knowing this, and I think
(17:12):
a lot of you in your field know this already.
What is happening in adult medicine and cardiology to increase
this exposure to the internal medicine residents and general categorical
cardiology fellows to maybe stir up a little more interest.
Speaker 3 (17:27):
Yes, I think many of the ADHD programs have incorporated
ADHD rotations during General Cardology fellowship. We often see this
rotation introducing the third year of fellowship, but at this
point many of the fellows have already decided on a
career path, so having it early, like in the second year,
it would be much more ideal because they still need
(17:49):
some foundational imaging skills to be able to rotate in ADHD.
In the internal medicine residence, I think that there's a
lot of opportunity including mentorship with an ACHD physician, clinical
exposure with rotations, or taking care of ACHD patients in
(18:09):
the carreology service or in the CCU as well as
educational opportunities, and here I wanted to highlight the global
conversations in ADHD webinar series where we engage twenty five
residents and cardology trainees across six countries to present and
lead case based discussions in ADHD. We have an upcoming
(18:34):
proposal where we're going to publish the results where we
engage approximately eighty six countries and over two thousand registrations
across the globe.
Speaker 2 (18:45):
Wow, very interesting, congratulations on that.
Speaker 1 (18:49):
You know, the thing that kept coming back to me
was the lack of jobs and adult continer heart disease,
which seemed to be an important reason that people choose
not to pursue it. But wondering, how do you square
the fact that there are too few positions with the
gigantic number of patients that exist. I mean, what other
(19:09):
reasons that the number of positions don't match the needs?
I mean, not only do they not match the needs,
but you're basically explaining that hospitals don't even have to
pay these doctors as much money. And yet still there
seems to be a very large mismatch between the need
and the actual delivery care deliverers.
Speaker 3 (19:29):
Yes, I think that there are multiple factors here. Whereas
there are several hundred jobs in general cardiology across private
and academic centers with broad geographic variety, in ECHD, we
only have a few teams, mostly in academic centers at
medium to large cities. But having said this, they're up
(19:51):
to twenty four graduates per year and job security is warranteed.
There's also a high job satisfaction. Of the recent graduates
report that their job represents their ideal or near their
ideal job. The patients also may not be transitioning full
(20:13):
from pediatric to adult congenital care. Other patients are lost
to care due to the social determinants of health and
maybe also really sparse in terms of their geographic location,
and that makes it harder to centralize these services. There's
also a lot of patients who are still able to
(20:36):
only access general cardiology care locally, and the article by
Kayla Lopez had demonstrated that the greatest majority of the
US population is generally more than one hour away from
an ACHD center, So that puts in context that despite
(20:56):
the volume of patients may be large, they might be
very unequally distributed, and some of them may not be
able to access the right care because of the social
determinants of health.
Speaker 1 (21:08):
That really highlights the importance of transition that Kayla is
so strongly supportive of.
Speaker 2 (21:15):
Well for those in the audience, We're.
Speaker 1 (21:16):
Coming to the end of the week and the end
of the day, and doctor Bravo Cheimis was nice enough
to give us time at the time of the week
where we all know we get a million phone calls.
Speaker 2 (21:25):
I'm sure you're very busy, so I'll finish it up here.
You know.
Speaker 1 (21:28):
The respondents to your survey offered their own thoughts on
how to enhance interest in the pursuit of adult congeneral
heart disease amongst trainees. As a very experienced, busy adult
congeneral heart practitioner, I'm wondering, what do you think should
be the central components of a strategy to increase the
ADHD workforce and interest among young people who are trainees.
Speaker 3 (21:52):
I think that spark in the firing ADHD takes a village.
I have reflected a lot on my personal history, and
I can say that this field is for those who
see the patient as a whole, as a whole human
with complexities inside and outside the heart. And for people
who love solving problems thinking outside the box. Early exposure
(22:14):
is key and we need to increase awareness about this
field engaging the trainees in community activities such as pediatric
heart camps for example. They don't need to know all
the ACHD complexities to participate here. They can be volunteers.
They can also participate in global health experiences, clinical rotations,
(22:36):
and also engage them in educational activities such as the
global conversations in ADHD that I mentioned. Finally, research experience
are also important to keep the fire burning because many
of the internal medicine residents are looking for that interesting
case to publish, and what a better case than in ADHD.
(22:57):
I would say mentorship, but it is also fundamental and
here I wanted to pay tribute to doctor Latta Larde
who saw something in me back in Perule when I
was a medical student and created a pipeline program to
train in the US. Also to doctor James twelve with
whom I had my first pediatric carriology rotation and congenital
(23:19):
heart surgery exposure during his time in Milwaukee, Doctor Putong
who demonstrated that a strong image and foundation opens the
door to ADHD and finally to doctor Jami labl Whosong,
who's extreme ownership demonstrated what it takes to be in
a leader in ADHD.
Speaker 1 (23:37):
Wow, those are some powerful names you just mentioned. I
guess it's no surprise what you yourself are becoming a leader
within the field. So, doctor Bravochheimes, I really appreciate you
joining us this week again on the podcast highlighting what
is a very big problem that I often refer to
it as the tsunami of patients that are coming towards us,
(23:58):
and so it definitely takes the village to take care
of these patients, and I'm learning to encourage people to
become part of the team that does that. I want
to thank you and congratulate you and your co authors
on this very important survey study.
Speaker 2 (24:11):
Thank you very much, Thank you pass again.
Speaker 1 (24:14):
Well, much as before, doctor Bravo Jaimes really well summarized
her work and the scope of this important problem. I
thought her comments about the sort of person who would
do well in this field to be of great importance.
As she spoke, I realized that one really needs to
be a complete doctor like our transplant colleagues or perhaps
oncology physicians, because these patients have so many different challenges,
(24:38):
and this notion really resonated with me as I thought
about the three adult congenital heart specialists that I work
with every day, doctor Ali Zaidi, Doctor Kaylee Hopkins, and
doctor Barry Love, who are each really complete doctors who
work hard to address the many problems that a number
of our ADHD patients face. This is not an easy task,
(24:59):
but when done right, it is clearly life changing and
maybe even life saving. Off air, doctor Bravochaimes explained that
there are some programs that are trialing two plus two training,
whereby the Internal Medicine Cardiology fellow can start the two
years of ADHD training in what would normally be year
three of categorical fellowship. This is apparently an experiment that's starting,
(25:21):
and I'm sure we'll learn more about how it's working out.
Given the clarity of her thought, I think there's not
much more for me to add of. That's once again
thank doctor Bravochaimes for her time this week on Pedihart.
To conclude this three hundred and fifty second episode of
Pedihard Pediatric Cardiology, today we hear the wonderful Spanish tenor
Jose Carreras singing the heartbreaking aria to kea dio Spiegasti
(25:46):
from the last act of Luccia di Lamomoor by Donizetti.
This is a live performance from nineteen eighty one, shortly
before Carreras developed leukemia, which he famously defeated after a
home mare transplant at the Fred Hutchinson Cancer Center in
the late nineteen eighties. Here how wonderfully his voice carries
(26:06):
throughout the hall with a beautiful tone. Thank you very
much for joining me for this three hundred and fifty
second episode, and thanks once again to doctor Bravo himis
I hope I'll have a good week.
Speaker 4 (26:17):
Ahead, Holly speed.
Speaker 5 (26:30):
See over Mozy.
Speaker 4 (26:47):
Lovel a, say.
Speaker 5 (27:05):
You wit.
Speaker 6 (27:20):
My turn.
Speaker 4 (27:25):
Got there in time?
Speaker 6 (27:29):
On my enma.
Speaker 4 (27:33):
The lo re normal wan to g wing t mo.
Speaker 3 (27:49):
T go.
Speaker 4 (28:23):
Oh, it's such.
Speaker 5 (28:45):
A study.
Speaker 6 (28:50):
Cosual and lo you totally love very myrm.
Speaker 4 (29:20):
Or lot in my norma.
Speaker 6 (29:26):
Would nature are very high normal? Where did I no?
I got to
Speaker 4 (29:50):
Oh m
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