Calling It Quits: Cath Lab Pioneers Grapple With When to Go and What Comes Next

Many prominent interventional cardiologists have been active since the birth of their specialty and see pros and cons to moving on.

Calling It Quits: Cath Lab Pioneers Grapple With When to Go and What Comes Next

Interventional cardiology remains a relatively young field, but it’s been around long enough that many physicians who took up catheter work in the early days are reaching the age when it’s time to start thinking about what comes next. For some, that’s full retirement, for others it means a change in career.

Still, the decision to stop active cath lab work is not an easy one and involves considerations around finances, family, lifestyle, and loss of identity.

“A lot of us were very young when we started doing this . . . and really our professional identities are very much connected to our being [a part of] the leading wave of interventional cardiology over the last several decades,” Bonnie Weiner, MD (Saint Vincent Hospital, Worcester, MA), a past president of the Society for Cardiovascular Angiography and Interventions (SCAI), told TCTMD. “So I think from that perspective it may be challenging to let go for some of us.”

Really our professional identities are very much connected to our being [a part of] the leading wave of interventional cardiology over the last several decades. Bonnie Weiner

Most of the interventionalists interviewed by TCTMD—some of whom were active long before Andreas Grüntzig, MD, performed the first balloon angioplasty in September 1977—agreed that age alone should not be a major deciding factor. Indeed, there are interventional cardiologists who choose to remain active well into their 70s. But, as many acknowledged, personal preferences and outside forces are not always perfectly aligned.

Is Age Just a Number?

Any discussion about how and when to leave the cath lab typically comes after decades spent performing procedures. That begs the question: how should age versus experience be factored into the equation? There’s scant data from the interventional cardiology literature about how operators’ skills change over time. Studies on surgeons, however, have shown that older practitioners have declines in strength, eyesight, dexterity, and cognition starting in their sixth and seventh decades of life. Knowledge and experience can compensate for some of the body’s wear and tear, but age-related declines occur nonetheless.

Physicians who discussed the issue with TCTMD universally concurred that a strict age cutoff to mandate an exit from the cath lab—a practice common in Europe—would not be appropriate because of variability in the aging process. Augusto Pichard, MD, who maintains a position at MedStar Washington Hospital Center in Washington, DC, and is medical director of Abbott Structural Heart, pointed out that some 80-year-olds can play an intense game of tennis, whereas others can’t walk to their mailbox.

Weiner, likewise, said that the decision about which age marks the right time to stop needs to be individualized. “I think the issue is not so much age, but at what point have your skills and responsiveness and ability to rise to the occasion, so to speak, started to diminish, and at what point does that start to make you—meaning us as interventionalists—uncomfortable that we're not providing the best care to our patients,” she said.

George Vetrovec, MD (Virginia Commonwealth University, Richmond), a past president of SCAI, said interventional cardiologists need to be honest with themselves about both potential declines in skills and their flexibility in terms of keeping up with new developments in an evolving field.I think that’s important particularly for interventional cardiology,” he told TCTMD. “I think short of true cognitive impairment or something that technically the interventionalist can go a long time, but I think everybody has to decide when they’re [at the point of where they should stop].”

Spencer King III, MD (Emory University, Atlanta, GA), a past president of both SCAI and the American College of Cardiology (ACC), said he was “born in medicine before interventional cardiology.” Indeed, King played a role in bringing Grüntzig to the United States to join the Emory faculty. He joked that he stopped doing procedures about 3 years ago “because I’m old.”

But in actuality, King explained, he pressed pause not because he couldn’t physically do it anymore but because he was no longer able to be fully engaged in the fast-moving developments in the field as he took on greater responsibilities in other areas. “So rather than be a low-volume operator, I chose to be a no-volume operator,” he said.

Rather than be a low-volume operator, I chose to be a no-volume operator. Spencer King III

King said he does not support mandatory retirement or a skills evaluation at a certain age because he’s seen European colleagues forced to stop doing procedures at the peaks of their careers because of forced retirement. That decision should not be based solely on age, he said: “I think a lot of people ought to get out when they're 50. Some people ought to stay in until after they're 80 maybe.”

Competence should be monitored, but that is already done to a certain extent through the hospital credentialing process, which involves a look at interventionists’ outcomes and may involve feedback from other members of the staff, King said.

Others agreed that that process at the hospital level was sufficient to monitor for any performance issues that might crop up with interventionalist cardiologists, regardless of age, although some remained open to some type of evaluation of late-career physicians.

Morton Kern, MD (University of California, Irvine, and VA Long Beach Healthcare System), a past president of SCAI, said mandatory screening—possibly at age 70—“would be a very judicious and measured approach to helping people into a transition phase.”

The difficulty would be developing a fair way to perform such an evaluation, however, which is perhaps why none of the major US cardiovascular societies have taken any formal steps in that direction. “How you set it up and what the criteria of performance are is challenging, especially when we have such an independent enterprise of physician practice,” Kern said.

Weiner said that mandatory screening could be considered if there were a validated tool to be used for that purpose, but that it should be applied to physicians of all ages, “because there is just as likely to be a young interventionalist who would have the same outcome on a testing tool like that as somebody who’s 70 and has 40 years of experience.”

Vetrovec was also open to some type of evaluation, though he remained cautious about how it might be used. “I think if it’s well designed and well thought through it might be reasonable, but I’m always concerned about people using that as a way to basically use age rather than ability as the decision,” he said. “I think that’s not appropriate, but I think some way to check skills and cognitive ability is not wrong.”

Leaving the Grind

For some interventional cardiologists, a desire to leave the daily grind of being called in at any time of day or night—and the associated physical toll—contributes to calling it quits in the cath lab.

Vetrovec said severe back problems—which can be related to wearing the heavy lead aprons during procedures—are probably the biggest occupational hazard that limits interventional cardiologists’ time in the cath lab. He said he hopes the problem will become less of an issue in the future with the advent of robotic devices that allow operators to sit away from the table.

Another issue in terms of the stamina needed to continue in the cath lab is the willingness to continue taking 24/7 calls, according to Cindy Grines, MD (Northwell Health, Manhasset, NY). At many hospitals, if you want to perform procedures, you have to participate in the call, making it difficult for operators who want to cut back on their case load to do so and potentially leading an operator to stop altogether, she said.

“There’s very little flexibility in interventional cardiology,” Grines said. But because it’s difficult for many to stop what they’re doing cold turkey, she added, “a lot of physicians that I talk to, they don’t really want to retire full time, they just want to get out of the grind of the physical labor involved in the cath lab.”

David Williams, MD (Brigham and Women’s Hospital, Boston, MA), who has been out of the cath lab for about 3 years now, also cited the exhaustion from responding to calls at all hours—in addition to the constraints put on personal time—as a potential reason an older interventional cardiologist would decide to stop doing procedures. “I think the STEMI call concept, which is incredibly important for patients and needs to be done, is tough on the physician,” he said.

Pichard highlighted the rewarding aspects of being involved in interventional cardiology. “We did tons of cases and it was exciting, stimulating,” he told TCTMD. But, he added, those positives are balanced out by the demands: the long hours and stress associated with handling emergencies around the clock and staying up to date on developments in the field.

That push and pull of interventional cardiology—the excitement and stimulation on one side and the grueling time commitment on the other—often leads interventional cardiologists to a natural point where it just makes sense to move on to something else and let the next generation take over.

When It’s Just Time to Go

Vetrovec told TCTMD that when he retired from clinical practice in 2015 after nearly four decades in cardiology he felt fine both physically and mentally, but thought it was the right time to leave.

“I didn’t feel like I was leaving prematurely,” Vetrovec said. “I did my last procedures over the age of 70, so I felt like I had given back the educational investment in me.”

Peter Block, MD (Emory University), said that he was emerited as of June 1, 2017, but was mostly out of the lab for around 2 years before that, except for the occasional case here and there. By that point, he felt that it was time to retire, having started practicing in 1970, several years before the birth of angioplasty.

After stints at Massachusetts General Hospital and Oregon Health & Science University, Block was recruited to start a structural heart disease program from scratch at Emory in 2001. By 2017, he had succeeded in building a world-class program. “I felt that it was time to let the younger people that I had trained in that period of time take over the clinical trials and take over the steering wheel of this sort of luxury liner that had been produced,” Block said. He did a “gradual, soft-landing transition” in which he trained people to take his job before stepping aside.

Pichard’s exit from the cath lab also was a gradual one, driven both by a sense of “mission accomplished” and by the pull of other opportunities. He stopped doing procedures last year, taking a full-time position with Abbott to teach operators around the world how to use new percutaneous valves.

Pichard made the decision to stop when proctoring began taking up more and more of his time. What finally severed the ties to the cath lab was a visiting professorship in South Africa for 3 months in 2016, which left the MedStar team on its own, he said. “When I was absent for 3 months, the team really had to learn to be without me and they did beautifully.”

He was still taking on the most complicated cases when he decided to leave the cath lab. “I felt I was at the peak. And that’s what I’ve been saying to others. That’s the time to stop. You don’t want to let any subconscious decline happen [or] wait for someone to tell you you’re declining,” Pichard said, adding that he’s very happy making the transition.

Carl Pepine, MD (University of Florida, Gainesville), a past president of the ACC, decided it was the right time to leave the cath lab when it became difficult to split time with his other professional responsibilities. Pepine started the interventional cardiology program at the University of Florida and was an interventionalist for 30 years. Around 2000 or 2001, Pepine, who was also serving as chief of cardiology, began to feel stretched thin. Trying to split his time between the cath lab and his leadership position with the hospital, both of which deserved a total commitment, was not fair to patients or to either job, he said.

I felt I was at the peak. . . . That’s the time to stop. You don’t want to let any subconscious decline happen [or] wait for someone to tell you you’re declining. Augusto Pichard

So he moved away from the cath lab and fully into his other role, starting what he called his “second career.” A few years ago, Pepine retired from the university but quickly realized that that wasn’t the right move for him. After just a few months, he returned to do research and see patients, having shed both his interventional and administrative responsibilities. That’s what he continues to do now.

“So I’ve sort of had three careers, and I have to say I’m enjoying it more than ever,” Pepine told TCTMD. “The bottom line is I’m still seeing patients in clinic, still enjoying the practice more than ever. I like to talk to patients. I always did. It’s one of the reasons why I went into medicine in the first place.”

Concerns About Loss of Identity

Although fulfillment can clearly be found outside the cath lab, several interventional cardiologists interviewed by TCTMD said that fears of losing one’s sense of self and purpose can complicate the decision to stop doing procedures.

Many interventional cardiologists contemplating retirement or a move away from doing procedures have been pioneers in the field and have been integral in many of the advances that have occurred, Vetrovec pointed out.

“So I think stepping away from it does sometimes make people a little anxious as to how they’re going to feel, how they’re going to be perceived, who they are, and I think that’s an interesting part of it,” he said.

Williams, who was the fourth operator to perform angioplasty in the United States, said that nearly all of his clinical activities involved doing procedures from early in his career and much of his development was tied to the cath lab. “So for me it was my identity,” making it harder to stop doing procedures, he said.

Kern said it’s important to figure out how to retain income and continue to feel valued when leaving the cath lab, “because I’d say the biggest impact of the retiring of an interventionalist is the loss of self-importance or self-image. Your self-worth is diminished when you step out of a role that you’ve been in for so many years.”

Your self-worth is diminished when you step out of a role that you’ve been in for so many years. Morton Kern

Kern got a taste of that feeling when he moved from an academic to a private practice setting about 12 years ago, even though he continued to do procedures. “I lost self-worth hugely, and it was very painful,” he said. “It was also very enlightening that this was going to be a problem as retirement approaches.”

He coped with those feelings by continuing his participation in SCAI-related activities, giving lectures, consulting, and finishing leftover academic work. But it was challenging, he said, to maintain visibility in the academic world as he worked in private practice. After a year and a half, Kern was offered a chance to return to the academic setting with a position at the University of California, Irvine, and he jumped at it.

But fears about a loss of identity without having catheters in hand have not plagued all interventional cardiologists who have put in several decades in the field. King described being around in the earliest days of interventional cardiology—“We were the cowboys on the wild prairie and everything was difficult,” he said—but indicated that the decision to stop doing procedures was not a tough one for him. Working in the cath lab was always just one aspect of his professional life, joining teaching, conducting research, performing clinical trials, and taking up leadership positions in professional societies.

“I’ve often gotten from other people that [not performing procedures] is much more traumatic than I experienced,” King said. “So maybe I’m an outlier. For me, doing it was a great part of my life. I've been heavily engaged in it from the point of bringing Grüntzig here to America and working with him directly for those 5 years and kind of leading the charge in many ways for the academic aspects of interventional cardiology. But I just haven't had the withdrawal or the feeling that I really need to be doing those cases.”

“There’s a lot more to life than the cath lab,” King added.

Pepine agreed, noting that a skiing accident helped him realize that giving up procedures was not the end of the world. He could not perform procedures for a couple of months after his accident, he said. “I realized I didn’t need the cath lab to live and feel good. And that’s what made me realize, hey, there’s another life here.”

Planning for a Second (or Even Third) Career

Retirement from any career can mean the freedom to pursue parts of life—travel, photography, painting, music, and other hobbies—that have fallen victim to lack of time. This may be especially true for physicians, who put everything on the back burner to pursue their careers from a young age. For interventionalists, it may mean a shift to other areas of cardiology or medicine in general, allowing them to retain income while maintaining the spirit of service that drew them to medicine in the first place and share the knowledge and experience they’ve accumulated over the years.

What seems to be important is having a plan in place, so as not to be ill prepared when it comes time to stop.

“The sooner you think about what your options might be and what you might want to do, I think the better off you are,” said Vetrovec, who has continued to consult for industry and the US Food and Drug Administration and participate in activities for the ACC and SCAI. “You’re still an interventional cardiologist but you’re not practicing it, so I think you’ve got to be willing to think about and accept the fact that you’re changing your career.”

Weiner, who has maintained a part-time workload in the cath lab for about the past 15 years since leaving a full-time academic position, also espoused the importance of planning ahead.

“Whatever you're doing with the rest of your time, whether it's full time or not full time, it really is a function of finding things that are mentally and intellectually stimulating and fulfilling,” she said. “I think the challenge for a lot of us is that we have run at 120% of effort or more for most of our careers and it's hard to put the brakes on that abruptly. So planning the transition, planning what those alternatives are, I think is key.”

Keeping busy after leaving the cath lab, regardless of whether it’s with medicine-related work or other types of activities, was a recurring theme in discussions with interventional cardiologists.

“It’s not in gardening 2 hours a day that you can compensate such a loss,” said Marie-Claude Morice, MD (Cardiovascular European Research Center, Massy, France), adding that it’s certain “that you will be depressed if you just stay at home doing nothing.”

Morice, who was forced out of the cath lab by French law that mandates retirement at age 65, said it was difficult to stop doing procedures. “There is a very special relationship with the patient, with their families. It’s very painful,” she said, particularly because she left when she was at the peak in terms of knowledge, experience, and the ability to teach fellows. Morice said that can also be seen as a positive, however, because she didn’t experience any decline in skills before she left.

In her second career, Morice keeps busy as CEO of a contract research organization, “which is good because I can use my experience but in a different field.”

Kern, who stopped taking call about 3 years ago but continues to work in the cath lab 1 day a week teaching fellows and performing midlevel interventions, said that his colleagues who have successfully made the transition out of the cath lab have followed a variety of paths, including seeing patients as a general cardiologist, teaching, continuing to consult with interventionalists, going into hospital or academic administration, and moving to industry.

Making plans and maintaining connections is key to changing careers successfully, Kern said. “It would be a good thing for those of us who are moving to retirement to have a strategy to manage the psychological impact, and it’s conquered mostly by maintaining personal contacts with friends and acquaintances,” he said. “Those people who go into retirement and become isolated are the ones at most risk for depression and withdrawal, so the best coping strategy is to maintain your personal interactions, your social network.”

Citing a “huge deficit” in the cardiovascular work force, Pepine urged interventional cardiologists to not give up on cardiology when evaluating their post-cath lab options.                                                                                                                                            

I see a lot of my younger colleagues who are just so frustrated with what’s going on in medicine and what they've seen over the last few years that they just don’t want any part of it anymore,” he said, referring to aggravation with reimbursement, documentation, and recertification.

But there are many parts of medicine and cardiology in which they can make a worthwhile contribution, Pepine said. “I would encourage them to try it before they give up and move to being a stockbroker or something like that.”

In addition to remaining intellectually stimulated and sharing accumulated experience, shifting career directions rather than retiring also has the benefit of maintaining the level of income to which physicians have become accustomed. This is an important consideration when looking into next steps, Block said.

“If you run out of money at the age of 85 when there’s no place else to turn, that is not a good option,” he said. “Nobody likes to raise their hand and say, ‘How do you know how much money I need to have in order to live?’ That’s a tough question, and you need to have professionals that can help you with that. If you try to do it yourself, you'll probably get it wrong.”

Open Up the Luggage You Left Behind

Even if they are in a good position financially to retire, interventional cardiologists tend to keep busy after exiting the cath lab.

“I had a friend that I thought had retired—by my definition—prematurely and he looked at me and he said, ‘You know, George, if I were any busier I’d have to hire a partner in retirement,’” Vetrovec said. “And I think that’s an important thing for people to realize. Because I think it’s not the end of the world. It’s hopefully an opportunity to do some different things.”

King, for one, has found plenty to fill his days. After stopping performing procedures, he remained active in hospital administration, continued research activities with Emory and Georgia Tech, and finished his 10-year tenure as editor-in-chief of JACC: Cardiovascular Interventions. He now serves as chair of the board of trustees for Mercer University.

“It didn’t create any spare time when I quit the cath lab,” he said, adding that he doesn’t miss doing procedures and gains satisfaction from reviewing and making suggestions about challenging cases.

Block, who spends 1 day a week at Emory working with clinical research fellows, medical students, and undergraduates on looking at databases and writing research papers and 1 day at the cardiac catheterization conference at the VA hospital, has conflicting feelings about leaving procedures behind.

He said he misses it “when I watch somebody struggle, and I miss going in and helping them or showing them how to do it more easily. But I don't miss wearing the lead and bending over for 2-and-a-half hours or 1 hour, or even 30 minutes. So it’s a mixed bag. On balance, I’m not unhappy that I no longer go to the lab.”

Block—whose free time is filled with wood turning, sketching, and watercolor painting—had some advice for those contemplating retirement: make sure you have an activity that will make you intellectually happy and fill your days, perhaps an interest that got pushed aside by the demands of a career in medicine.

He illustrated that point with a parable borrowed from an old medical school roommate. “When we all got on this really fancy express train called medicine and went to medical school, we boarded a train that was unbelievably upper-class, fast, exciting, and full of challenges. It is now time to get off the train,” Block said. “As you get off the train and get back on the platform, look back on the platform that you embarked upon so many years ago and see what luggage you left behind. Open it and then go ahead about your life.”

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Comments

1

Robert Kelly

9 months ago
Being able to work as a doctor for as long as you want is a great privilege. I hope to have that choice. Still like surgeons there is a time to let younger doctors do the higher risk procedures but still teach and instruct them in case you might need them to do your own angioplasty / stent.