Gregory Weiss, MD: Has the Time Come for a Cardiometabolic Subspecialty?

Gregory Weiss, MD

A century ago if one were to seek out a physician, they would likely have had only two specialties to choose from, a surgeon or a medical doctor. Even earlier those two would be one and the same. Now, the medical profession consists of dozens of specialties and likely over a hundred subspecialties.

The argument for subspecialization is sound and exists in its purest form within the old saying, a jack of all trades is a master of none. However, some would claim that too many subspecialties only serve to dilute or minimize the parent specialty negating the foundational work already done. So, what is the answer and how much is too much?

The most common and valid reason to create a new subspecialty is to address newly discovered disease categories that may benefit from a more focused approach within an established specialty. It is well known that diabetes, heart disease, and obesity are increasing globally. It is further known that this cluster, known as the metabolic syndrome, increases the risk for cardiovascular (CV) events and death.

Classically, diabetes is managed by endocrinologists who are sub-specialists of internal medicine. Likewise, cardiologists treat patients with heart conditions and are also subspecialists of internal medicine. There is a clear intersection between the work of endocrinologists and cardiologists. However, this is true of most specialties and subspecialties in medicine. So, what would warrant either discipline claiming dominion over patients with cardiometabolic disease?

Recent investigations have led to a discussion with regards to creating a cardiometabolic medical subspecialty. Research has revealed that drugs used to treat diabetes are independently associated with improved cardiovascular outcomes and reduced mortality related to CV disease.¹ In particular the glucagon-like peptide-1 receptor agonist (GLP-1) class of drugs and the sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to improve CV risk, mortality, and heart failure.² The question becomes, who should manage the patient with type 2 diabetes and a glycosylated hemoglobin (HbA1c) of 9% who has been admitted for a non-ST elevation myocardial infarction (NSTEMI)?

I believe that there is a strong argument for cardiologists taking a bigger role in managing patients with cardiometabolic disease. While endocrinologists and diabetologists are focused on managing blood sugar and minimizing the risk of diabetes-related complications, the most deleterious complications from diabetes remain cardiovascular disease and death from cardiac events. As such, once an obese, diabetic patient develops cardiovascular disease, they will come under the care of a cardiologist. Andrew Krentz, MD, and colleagues in the UK believe that the cardiologist, as the cardiometabolic specialist, should take the lead in coordinating care aimed at reducing cardiovascular risk including management of metabolic disease in patients with established cardiovascular risk.³ Robert Eckel, MD, would agree and go further by calling for a cardiometabolic subspecialty training program with its home in cardiology.²

While many find the idea of a cardiometabolic specialty appealing, others do not. Turf wars are common in medicine even without the specter of business being funneled away or diminished authority over a body of work. Endocrinologists would argue that there is no need for a cardiometabolic subspecialty since they have been leading that work for some time. Further, creating a new subspecialty that largely deals with endocrine disorders that coincide with cardiovascular disease would further diminish the number of physicians going into endocrinology—an already underrepresented group. Cardiology itself has become a procedure driven specialty creating more revenue than specialties that classically treat chronic medical conditions, a fact adding to the resistance from endocrinologists.

So, who is right? The answer is neither and both.

There is no doubt that we need more endocrinologists. Cardiologists are not going to be managing obese 18-year-old patients without cardiovascular disease just as endocrinologists will not be performing cardiac catheterizations on their diabetic clients.

In my opinion, there exists plenty of red meat to be had by all. The benefit of developing a cardiometabolic subspecialty lies in the spotlight it would create leading to research and advancements specific to the interplay of CV risk and the metabolic syndrome. The argument that doing so would detract from either endocrinology or cardiology could be satisfied by including both specialties in the training programs. Allowing both cardiologists and endocrinologists pathways to certification in a cardiometabolic subspecialty solves most of the problems with regards to marginalization eliminating the tendency for specialties to silo medical conditions into their own domain. Further, combining specialties may foster more collaboration and a more patient-centered approach. After all, at the end of the day, it is really about the patients, not about our specialty’s numbers or recognition for our efforts.