Cardiology!

[ffp]

Ok, here's my post on the specialty that's closest to my heart! :D

Cardiology is one of the subspecialties that you apply to after 3 years of IM residency. Cardio itself is 3 years, then you can further subspecialize after that (usually 1-3 years, but can take as long as you want if you choose multiple subspecialties).

I developed an interest in cardio in first year med school because it's the first topic we covered that made any sense to me! I've always loved math, physics and logic. In school, I did well in these subjects without studying, because I found that if you had a solid understanding of the basics, you could reason out the answer to any problem. I HATED classes like bio which required memorization of seemingly unrelated facts.

Well, the first few months of med school were miserable because they seemed like straight memorization (infection, immunity, inflammation, endocrine, pulmonary). My head was spinning with cytokines, bugs and drugs, and hormones. It wasn't very much fun :(

Suddenly we were in cardio block. The heart functions as a pump. If you can understand some basic pressure-volume relationships, you can understand heart failure and valvular abnormalities! You can understand why certain heart sounds and murmurs go with certain conditions, and how they might vary with maneuvers. You can reason out how all of the cardiac drugs act, and how they might be used to treat different heart conditons! ECGs baffled me until my PBL preceptor explained that it is all vector geometry. Suddenly it made sense! I loved cardiology because it all seemed so simple, beautiful and logical.

Long story short... I did some cardio research and electives in med school (some experiences were better than others). I explored a few other specialties (including peds cardio), but eventually ended up as an adult cardio trainee! Here's the lowdown on my specialty:

I like cardiology because it is a great combination of thinking and doing. Cardiology is more "active" than some of the other IM specialties. Often, your patient will have a serious, acute condition, and you can act immediately to treat it (ie. cardiac arrest, arrhythmia, MI, pulmonary edema). In that sense, you can instantly see the result of your actions, and it provides some instant gratification. There's higher patient turnover than on the IM service. Patients tend to come in, get treated, and go home within a few days. On the other hand, it's still more of a cognitive specialty than surgery or EM. Some patients have weird and wonderful conditons (cardiomyopathies, congenital diseases, arrhythmias) that require thorough workups to determine the etiology. Some patients have chronic conditions and require long-term follow-up.

Cardio is great if you like doing procedures. As a cardio fellow, you get to perform echocardiograms and diagnostic angiograms. 8 months into my fellowship, I've done ~200 diagnostic angiograms on my own already! You get to put in intraaortic balloon pumps and do lots of central lines, arterial lines and temporary pacemakers. You gain some exposure to electrophysiology studies and transesophageal echocardiography.

Even if you think you are no good at procedures, you can still do cardio. I always had trouble with central lines and felt I was no good at procedures. After a couple months of cardio, I had so much practice that now I can get a line in no time! As long as you like doing procedures and are willing to try, you can still do cardiology!

From general cardiology, you can subspecialize in many different areas:

Interventional cardiology (angioplasty/stenting, percutaneous valves, sometimes ASD/VSD closures)

Electrophysiology (arrhythmias, pacemakers, implantable defibrillators)

Echocardography

Nuclear cardiology

Imaging (Cardiac CT/MRI)

Congenital

Heart Failure

Transplant

Some people will do a combination of subspecialties (ie. echo + congenital).
Most people spend some time in their area of expertise (ie. 2-3 days/week in the cath lab or reading echos), as well as some time seeing patients in the clinic, doing treadmill tests, or reading Holter monitors. Most cardiologists also participate in a call rota looking after the CCU, ward and inpatient consult services as well.

Cardiology is full of new advances. Right now, interventionalists are starting to do valve replacements in the cath lab (something that has traditionally involved open-heart surgery). There are new advances with imaging technology. Cardiac CT and MRI are in their infancy now, but have a promising future. There are lots of new advances in electrophysiology. Stem cell therapy for regenerating damaged myocardium is also a current hot topic. It's an exciting time to be entering the field!

Lots of people knock cardiology for being a "bad lifestyle" specialty. This is true to a certain extent. People have heart attacks and cardiac arrests in the middle of the night, and need someone to look after them. It's not like rheumatology or endocrine where an after-hours emergency is rare. That said, some of the cardio subspecialties are more lifestyle-friendly than others. An interventionalist can expect to be called in most nights (s)he is on call. An echocardiographer is still called in (albeit less frequently) for urgent transesophageal echos at night. An electrophysiologist will RARELY be called at night, and most problems can be handled over the phone. A nuclear cardiologist will NEVER be called after-hours!

Even with the busier specialties, the amount of call you do will depend on the size of your call group, and the arrangements you have worked out. If you are 1 of 3 interventional cardiologists, your call is 1 in 3. This becomes a lot nicer if you are 1 of 10!

A cardiology fellowship is very busy. No doubt about that!!! Right now, I am doing 7 calls/month (plus whatever moonlighting shifts I pick up). I compare this to my friends in heme, rheum and pulmonary fellowships who either do NO call, or might get called in once/month! Still, I think it's worth it to be doing what i like to do. Different programs vary in terms of fellow call, but it's pretty standard to do 7 call/month in your first year, ~5 in your second year, and ~3 in your third year. For most programs, it's home call. I review all admissions and consults with the junior resident. If the patient is stable, and the junior is comfortable managing them, I can review over the phone. If the patient is unstable or requires admission to CCU, I have to see them in person. I have to see all admissions/consults before 8am signover the next day. If a patient goes to the cath lab at night, I actually get to scrub in for the procedure!!!

As a fellow, I also take all phone calls from doctors in the city or the periphery who have cardiology questions. They tell me about patients over the phone and fax me the labwork or ECGs. I then either give management advice over the phone, arrange outpatient testing and follow-up, or, if required, I arrange for the patient to be sent to Saskatoon for work-up/admission.

There is always an attending on call for me to review these things with if I have questions. The attendings are good at coming in to help if the junior and I are over our heads.

As fellows, we rotate through different rotations. Here's my PGY-4 schedule:

July - Echo
August - Cath
Sept - Cath
Oct - Echo
Nov - CCU
Dec - Ward
Jan - Research
Feb - Echo (elective)
March - Treadmills
April - Nuclear
May - CCU
June - Consults

Next year, I'll have rotations in pediatric cardiology, CV surgery, and electrophysiology as well as more echo, cath, CCU, ward and consult.

As far as remuneration goes, cardiology is the highest-paying IM subspecialty. Generally, interventionalists make the most, because they do the most procedures and a lot of it is done after-hours (which means special premiums). The specialties with fewer procedures earn less, but most cardiologists will earn at least $300K.

It is a busy lifestyle, but I look at it this way. Right now, I am VERY busy, but I like what I am doing and time flies by quickly. if I was doing endocrinology, my days would be 9-5, but every minute would be boredom and drudgery. I therefore consider cardiology to have a much better lifestyle! Once you finish your core fellowship, you can choose a less-busy specialty. You can choose to join a large call group, or job-share with someone. There are options for people who want lives outside of medicine (and most of us do!)

Right now I am trying to decide between electrophysiology and interventional. Aaah, decisions, decisions.

If you have any questions about cardio that I haven't answered, fire away!

[OttawaURookie]

ffp, wow, your posts are just amazing. Really really useful.

I have two questions for you:

1. After I finish my undergrad I will be around 26 and applying to med school hopefully. After med school is done I will be close to 30 and starting a residency. (which is not too bad in terms of age I guess?) Now you said you did the 3yrs of Internal Medicine and then you decided to subspecialize. Now, my problem would not be doing three more years if I had the standard pay for that area, but I would wager since you are a cardiology fellow now, you still have the lower pay till you finish that? That would bother me a lot more. (since I'd want to get rid of those debts as soon as I can)

2. And you said that your strength in physics, math and logic was what made you love cardiology and ultimatley enable you to have success. In all the different subspecialties of internal medicine, what subject(s) strength may give you a better chance of success? For example, Biology and Chemistry were always my strengths, while Physics I had to work really hard on and my mark was still only a bit over average.(this was in grade 11, only took grade 12 Biology)

[ffp]

Hi OttawaURookie!
30 is not old to be finishing med school!

Your pay goes up a few thousand dollars each year of your residency. I don't know my exact pay scale off by heart (we just got a new contract), but I can post it or PM it when I get home. In PGY-6, my final year of cardio, I'll earn ~$61K as my regular salary.

As you become more senior, some schools offer opportunities to augment your income by moonlighting. U of S is one of the best schools for this. Once we do 2 months ICU, 2 months CCU, and pass LMCC2, we can moonlight up to 72h/month, at $100/hr... so that's a potential extra $7200/month. Most months, I moonlight ~40hours... but it does add up! My income will break 6 figures this year. Once I pass my internal medicine licensing exams (hopefully in April, fingers crossed!) I can do locums as an internist as well. You would have to check with each individual school for their policies on moonlighting.

As to your second question... my interest/aptitude for math and physics is what attracted me to cardio as a student... but you don't necessarily need that to enjoy cardiology or be a good cardiologist. same with the other specialties. Often, you'll find that you really enjoy the THEORY behind a particular specialty, but once you get out on the ward and start seeing patients, you dislike it (or vice versa). For example, I loved the theory behind neurology, but when I got out on the wards and started seeing neuro patients, I realized that I didn't like it. I hated hematology in the classroom, but clinical heme is kind of cool! I don't think there's any way to predict it. You just have to get out there and experience the different specialties for yourself.

This is why I tell people to keep an open mind. Sometimes we go into a rotation with a pre-conceived notion that we will either love or hate it. Try not to jump to early conclusions... after all, you're trying to decide what you'll be doing for the next 30 years! Make the most careful and informed decision you can!

good luck :)

[tarzi]

you're one of the best posters on here ffp :)

[Blake]

you're one of the best posters on here ffp :)Indeed. Cards is a pretty cool field, and probably the main reason why I would consider IM.

[spade]

Hey ffp,

Just wondering...what turned you against going into paeds cardio? I find that paeds cardio is so much more diverse in terms of what you see and do...and more rewarding too! (but I guess that one's subjective)...

spade

[ffp]

As a med student, I actually spent lots of time in peds cardio. U of A has a great program, and I worked with a wonderful mentor (Dr. Coe). he told me at one point that I would be bored with adult cardio because the patients are all the same. "Coronary artery disease?" I asked naively. "No... 4 chambers, 4 valves", he said. :D

Peds cardio is fascinating and diverse, and you do see a lot of weird and wonderful things. Sick kids are always kind of sad to deal with, but you don't have the same problems with self-inflicted disease that you have in adults (3rd heart attack, obese, smoking, noncompliant with diabetes meds).

it was a VERY tough choice for me come CaRMS time, and in fact, I did apply to peds as well as IM. What it boiled down to is that I got interviews everywhere for IM, but very limited peds interviews, and mostly at places without cardio programs (as my interest in peds cardio came late, and peds was competitive in my year). Sometime between match day and ranking, I also reached the conclusion that an IM residency would be easier for me to stomach than a peds residency (as I would have to do one or the other before entering cardio). I couldn't stomach the poor kids with weird genetic diseases who would never have a chance at normal life. I couldn't handle some of the difficult parents, and I really disliked the general peds clinics... reminded me too much of family med. Adult IM has its equivalents, but I just thought it was a better fit for me.

Not that it influenced my decision all that much, but peds cardiologists are much lower-paid than their adult counterparts.

So far, I think I made the right decision for me, but it would be a very individual decision.

Good luck :)

[tarzi]

ffp,

what are some of the negatives about cardiology and IM in general?

Are the hours bad? Are you on call? I read somewhere that the hours for cardiology are really bad - but I don't see how this can be.

Is there opportunity for you to split your week into clinical time and research/teaching time? Do cardiologists ever go into private practice or do most work for hospitals?

[leviathan]

Nice post, ffp. Cardiovascular physiology has always been my favourite topic in university, with respiratory following in second (probably because of their intimate relationship). I love all of the very concrete facts about cardio like understanding all the stuff about preload, afterload, cardiac output, blood pressure determinants, etc. And even with the diseases, it is very little memorization and much more understanding to know why a dilated vs. hypertrophic cardiomyopathy develops, for instance.

I have no idea if I want to do cardiology though, because I'm sure the STUDY of cardiovascular physiology can be very different than the PRACTICE of it as a cardiologist. Is there any real way to find that out other than doing cardio during med school rotations?

[ffp]

leviathan,
Sounds like you like cardio for all the same reasons I did at first! From what I understand, you aren't in med school yet, right? this can make it harder to get clinical exposure. Cardio is a bit harder than other areas. If you like geriatrics, you can always work/volunteer in a nursing home. For peds....well, it's easy to find volunteer work with kids. You could volunteer with a cardiac rehab program, but this doesn't give you a real flavour for clinical cardio, since most of these patients have stable disease with few active issues.

I think the best thing for you to do would be try to shadow a cardiologist, or cardio fellow. At UofS, they have a program for aboriginal high school and university students to be paired up with a doc for a day. I met one of these students through the preceptor he was paired up with, and he shadowed me for a few mornings at work, as well as a few nights on call. If you could get set up with something like that, it would be sweet.

Also, I did some cardio research early on in second year med school, and my preceptor invited me to hang out in her clinic (despite the fact that I hadn't done my cardio clin skills yet).

You still have lots of time... Remember.. you have ~3 years of med school to decide on a specialty, and if you do IM, you have another ~2 years to pick a subspecialty... so don't worry about it too much at this point... you might change your mind several times :D

[ffp]

Tarzi,

for IM, I say these would be the negatives:

- You do have lots of older patients with multiple, chronic problems. This can be frustrating.
- There's not so much instant gratification as with other specialties (ie. surgery). Sometimes it takes a long time to see results of your work.
- You have inpatients to follow (unlike radiology, anaesthesia, ER, path
- You do get to do procedures, but not every day (like surgery or anaesthesia)
- Residency is one of the medium-busy ones. A medicine junior does ~1 in 4 call on CTU, and can be very busy indeed. It's not as bad as some of the surgical specialties, but definitely a lot worse than specialties like rad onc or path!!!

Negatives of cardio:

- It's BUSY. Cardio is the busiest of the IM subspecialties, and the patients can be sick. You'll often find yourself dealing with several seriously ill patients at the same time. It can be stressful
- The training is very busy. There is some variation in programs across the country, but a cardio fellow is always busy (especially in the first year). It's quite standard for a PGY-4 to do 7 calls/month, and some programs demand in-house call for the first 6-18 months. Because people can have MIs or cardiac arrests any time of day, it means you often are up all night on call.
- Some people complain because cardiology is "only the heart", and find it monotonous to deal with only one organ system

Once you're an attending, your lifestyle will vary depending on the subspecialty you choose. Most cardiologists do rotate through call on CCU/ward services. When you're on call, you're busy (for the reasons stated above), however, if you join a large call group, you might not be on call very often (ie. group of 16 cardiologists - call 1 week out of 16)

if you do interventional, you will be busy the nights you're on call! Again, call frequency depends on the number of interventionalists. More=less call/individual. The other subspecialties are not as busy as interventional.

Yes, in any specialty you choose, you can decide to be an academic or a private-practice physician. You can divide your time between clinical, research, teaching, and admin. This is true no matter what specialty you pursue. There are plenty of academic cardiologists and plenty of private practice. In some centres, academic cardiologists are salaried instead of fee-for-service. they tend to make less than their private practice counterparts (b/c they don't get to bill for procedures), but it frees up time to do other things - ie. teach, research. A fee-for-service cardiologist would not be remunerated for these things.

Nonetheless, private practice/ fee-for-service cardiologists can still be involve in teaching (albeit unpaid). This is what I hope to do one day.

[Kirsteen]

- You do get to do procedures, but not every day (like surgery or anaesthesia)
Hey there,

Just to add a wee bit: in my experience most surgeons don't have the ability to do procedures every day. Many I've worked with have protected OR time just two days per week and those who are fresh out of residency/fellowship, sometimes less. To belabour the point, I've seen some Interventional GI folk have more protected in-suite days per week than surgeons.

Cheers,
Kirsteen

[ffp]

Very true Kirsteen.

What I was trying to say is that as an IM resident, there will be opportunities to do thoracentesis, paracentesis, LP, bone-marrow biopsy, joint aspiration/injection, chest tubes, art lines and central lines.

The exposure to these procedures is not as consistent or as frequent as in a surgical or anaesthesia residency. There is A LOT of variation in how many procedures each resident is exposed to. For example... most residents in my year didn't get any chest tubes (or maybe 1 or 2). I got 7. On the other hand, I got 3 paracenteses (the bare minimum to meet our program's requirements). Most other residents got >10. It's just a case of which patients came in the day you were on call.

Some medicine attendings (regardless of subspecialty) perform and supervise all of the above procedures, and some do only a few, or none.

IM residency will afford you the opportunity to do procedures, but if you LIVE to do these things, and want to do them on a consistent, regular basis, you won't get it in IM residency (although you can in IM subspecialties like cardio or GI) :)

[leviathan]

leviathan,
I think the best thing for you to do would be try to shadow a cardiologist, or cardio fellow. At UofS, they have a program for aboriginal high school and university students to be paired up with a doc for a day. I met one of these students through the preceptor he was paired up with, and he shadowed me for a few mornings at work, as well as a few nights on call. If you could get set up with something like that, it would be sweet.....

You still have lots of time... Remember.. you have ~3 years of med school to decide on a specialty, and if you do IM, you have another ~2 years to pick a subspecialty... so don't worry about it too much at this point... you might change your mind several times :D
FFP, I am just graduating with my bachelor's degree right now. I definitely have tons of time to decide, so I think I will hold off on any shadowing until I'm in medical school (I'm in no rush!). As you said, I agree I will probably change my mind a million times over, anyhow. I do some volunteer work in an emergency department here and I've watched some cardiologists perform echos, which is pretty cool stuff. Other than that, the cardio stuff I've seen is mostly just dealt with by the emergency physicians before they get consults or admit patients up into medicine.

[physiology]

Hello FFP,

Look West FFP :) In BC, the well known cardiologists all bill over a $1 million a year. One reads echos...and I think the others are interventional.

Anyway, they seem fairly happy with their jobs too. Unlike the bitter ophthalmologists who i've met, who also bill over a million a year, but incessantly complain of the lack of OR time for their cataract surgeries.

Physio

[physiology]

The cardiologists in BC are like that too...they operate patient factories at times. They're also somewhat a bit arrogant and extremely territorial. But hey, that encourages innovation and the cardiologists can push all they want. When the radiologists & CV surgeons fight back, then the technology will get REALLY good :)

Cardiology is great too in that it's extremely well-respected. There's a considerable amount of funding and you're the exception if you don't have some sort of cardiovascular disease over age 50.

In terms of lifestyle, I heard it can be brutal. Call for CCU can be tough, depending on how good your resident is.

Anyway, I have heard that jobs can be scarce in BC, but let me tell you, there are lot of male cardiologists who are going to throw in the towel soon, so maybe when things are said and done, there will be considerably more jobs opening up.

[Curious P]

Jobs are scarce everywhere...

On that note, how are the job prospects for Cardiologists? Is there any way to predict what the market will be like in 5/10/15 yrs?


I've heard some rumours about a 5 year direct entry Cardio program in the works. Anyone else hear about such a program?

[ffp]

I've heard rumours about 5-year direct entry (ie. no IM residency required first). Right now they're just that - rumours. We actually debated this at one of the internal med half days last year. I've also heard rumours about cardiology going to 4 years (AFTER completion of IM, so that would make 7 years total). IMO, this is WAY too much, especially if you still have to subspecialize on top of that.

Job prospects for cardiologists are generally great if you choose the right specialty. If you do general cardiology, you will be GOLD. If you do echo and have your own machine, you can set up shop anywhere and pretty much start printing money. Cardiac imaging (CT-angio, MRI, nuclear) are going to be very hot commodities in the near future. EP is also still an expanding field with lots of opportunities. The problem comes if you want to do interventional. Right now, jobs in Canada are scarce. Some people tell me I won't have a hope of getting a job if I hope to do interventional (I'd be finished in 2011), while others tell me that lots of new centres will open up (ie. interior BC) and that lots of people will be retiring. I don't know who to believe. I won't let job prospects influence my choice of specialty, though.

[Curious P]

Thanks for the info ffp!

Here's an interesting article I found regarding the number of cardiologists in Canada: http://www.ccs.ca/download/position_statements/ross_ed.pdf

[ffp]

Thanks for the interesting article Curious_P. Yep... I sure would be happy with a shorter training program. won't happen for me, but maybe in the next few years.

Also, I wonder where they even found ANY cardiologists under age 35! I'm about as young as one can mathematically be at my stage of training (without being Doogie Howser), and I'll be 33 when I'm done :(

[Curious P]

Hey ffp, I have another question for you: What's the route to becoming an interventional cardiologist?

There's 3 years IM + 3 years Cardio + 2 years Interventional fellowship?
Also, what's the remuneration like when you're completing your interventional fellowship?

[Curious P]

Thanks again for all the great ino! I really appreciate it.

Why do you think it is that jobs are becoming more scarce? I would assume that with a demographic shift towards an older population, cardiologists would be in increasing demand, no?

[copacetic]

hey ffp, with all that moonlighting, doesn't that mean that you wont have time to be doing any research?

[physiology]

Hey FFP,

After doing CTU at UBC, one thing I've learned is the HUGE demand for echos! Get your own private echo machine & earn millions!

Physio :)

[seeking1]

May I just say ffp...THANK YOU SO VERY MUCH!!!

THIS. IS. THE. MOST. USEFUL. THREAD. TO. ME. EVER.

[e_is_hv]

Hey FFP, I have a question for you.

I'm a medical student right now at U of T. I did a double bachelors degrees in physics/electrical engineering. Right now I'm considering cardiology and radiology but can't make up my mind. I think Radiology is fascinating, but I'm not sure if I can spend the rest of my life just looking at pictures like a technician (no offense to the rads guys - we all know how important it is) - I really like using my clinical skills.

So I was intrigued about how there are fellowships in Cardiac Imaging (Echo, MRI/CT, SPECT/PET) for Cardiologists (specifically Ottawa has a ton). Why aren't the radiologists hoping up and down in anger about this? If you complete an imaging fellowship, does that mean you can bypass the radiologist, and order/interpret the kind of scans you're trained in? I'd like the ability to do that and see my patients (rather than spend all day interpreting scans for "patient" x).

Also, do you know if anyone does doulbe fellowships? Due to my background I also think Electrophysiology is fascinating and would consider doing both (as most programs are one year each). Thanks a lot, I really look forward to your response.

e_is_hv

[seeking1]

So wait...things are looking bad for interventional? :eek:

Also, how 'insane' is the interventional lifestyle?

[Ian Wong]

I think Radiology is fascinating, but I'm not sure if I can spend the rest of my life just looking at pictures like a technician (no offense to the rads guys - we all know how important it is) - I really like using my clinical skills.

So I was intrigued about how there are fellowships in Cardiac Imaging (Echo, MRI/CT, SPECT/PET) for Cardiologists (specifically Ottawa has a ton). Why aren't the radiologists hoping up and down in anger about this? If you complete an imaging fellowship, does that mean you can bypass the radiologist, and order/interpret the kind of scans you're trained in? I'd like the ability to do that and see my patients (rather than spend all day interpreting scans for "patient" x).

I am a PGY-5 in a US radiology program where we have both radiology residents and cardiology fellows reading out both cardiac CT and MRI in conjunction with our cardiac imaging attendings, half of whom are radiologists, and the other half of whom are cardiologists. We do both adults and peds cases, often with multiple cross-sectional studies each day.

I will give you the radiology-biased view, which is that I think our specialty is best placed to read both of these studies. Cardiologists have gotten heavily into the imaging game in the US because it is far more profitable to image a patient than it is to see them in the ER or in clinic. Echos, cardiac nucs studies, and caths all pay substantially greater than the admission and consult fees that are generated by seeing patients. It is these procedures that make cardiologists some of the highest billing physicians in all of medicine. To no one's surprise, chances are good that if you encounter a cardiologist, you will be getting imaged.

With both echo and nucs, cardiologists have been relatively protected from missing incidental findings, because both exams are completely focussed on the heart. In a similar vein, orthopedic surgeons don't really have much, if any increased liability when it comes to reading most plain films, since they are generally very strong at bone findings, and the rest of the plain film usually doesn't have enough soft tissue detail to alert you to incidental pathology.

Both CT and MRI, by their design, will image a much larger field of view, and it is in this area that there are often extensive incidental findings, particularly in the elderly and smoker/diabetes rich population that characterizes the highest-risk CAD group of patients. Lung masses, aortic pathology, adrenal lesions, renal cell carcinomas, hiatal hernias/distal esophageal carcinomas, and hepatic and splenic lesions often are in the field of view.

I still remember as an intern on my cardiology rotation watching a cardiac cath. Near the end of the procedure, I pointed out a rather sizable lung nodule which had been floating up and down with each patient respiration for the entire case. No one else in the room had noticed it.

On a different topic, cardiologists generally know very little about the protocols in generating cross-sectional images. Both CT and MRI are extremely complex in their imaging protocols. In order to repeatedly generate quality diagnostic images, a LOT of work goes on in the background to tweak sequences to optimize image quality and speed. These are things that radiologists are extensively trained in, and something that is not well addressed in any clinical specialty.

Additionally, a lot of the interpretive work is done using separate workstations and reconstructive software, to generate a manageable data set from the raw images. Without this post-processing work, you cannot interpret any of these studies. Radiologists have been using these workstations throughout the entirety of our training, as these features are often used in neuro-imaging, musculoskeletal imaging, and in all sorts of body and angio applications. Crossing-over to cardiac applications is easy for us. Cardiac CT and MRI require a very high degree of technical expertise, and you need this training and knowledge in order to do the exam justice.

As far as clinical correlation goes, I think for the bread and butter of cardiac CT, which will be in the evaluation of coronary artery disease and degree of stenosis, that radiology is more than adequately placed to do this. We have been grading stenosis and doing vascular interventions in Interventional Radiology for as long or longer than Cardiology has done coronary interventions. Similarly, we read all the peripheral vascular disease studies, both CT and MRI, as well as perform the angiographic studies. We are more than capable of evaluating the vascular anatomy and pathology on imaging.

In the same vein, cardiac MRI is often used as a problem-solving modality, with a fixed question being asked. For a focussed question, such as the gradient across an aortic coarctation, or quantification of the degree of shunting across an ASD, I think radiologists can easily perform these studies. I would agree that the average radiologist is not going to read an EKG at anywhere near the level of a cardiologist, but realistically, a lot of that clinical information is not available to the interpreting cardiologist anyway.

When I've seen cardiologists interpret nucs or echo studies, it is invariably a separate interpreting cardiologist from the individual who actually admitted the patient, and the clinical history supplied is typically just as useless as the clinical history supplied to radiologists for any of our imaging studies.

As ffp mentions, the turf war is primarily related to money. Cross-sectional imaging has the potential to drastically change the volume of diagnostic caths and therapeutic caths (hopefully decreasing the first, and increasing the second). It also has the potential to supplant a lot of the echos and nucs studies that are currently being done, and may have significant implications for the management of certain lower-risk patients presenting to the ER with chest pain.

At the end of the day, I see cardiologists reading the bulk of the cardiac CT and MRI, as long as it remains profitable. As the individuals who control the patient flow, they can direct patients either to their own scanners in their offices/imaging centers, versus sending them to radiology-based scanners. If, as we are seeing in the US, imaging reimbursement gets cut to the point where it is no longer profitable to own a cardiac imaging center, you will see cardiologists abandoning the imaging. It's the same reason why GI has never tried to muscle in on barium enemas or upper GI's, and why breast surgeons don't try to read mammograms; the reimbursement for time isn't worth the money or liability.

I do think for the few radiologists who are doing fellowships in cardiac imaging, that there will be more than enough work available in the boomer-generation for them to be gainfully employed.

However, because of the presence of other high-demand and high-reimbursing radiology subspecialty fellowships (ie. MRI, MSK, and Neuro), cardiac fellowships are relatively wide open at this point. Few graduating radiology residents want to be trained in cardiac imaging knowing that we might very well lose the turf war, when instead you could be learning how to crank out a head MRI in 4 minutes, or a knee MRI in 2 minutes. The ironic thing is that this will then become a self-fulfilling prophecy and we radiologists will lose cardiac CT/MRI due to manpower issues.

If that does come to pass, I hope that at the very least that we won't be asked to read these things on call from the ER. That would be a horrifying thought since these studies are very work-intensive, requiring much more man-power than virtually any other form of cross-sectional imaging.

Ian

[seeking1]

For simplicity's sake, can someone make a general year outline for the path to cardiology and interventional cardiology?

What I'm understanding is something like:

x years at uni > 3-4 yrs med school > 2 yrs residency > ~6 yrs cardio (general)

and I still am not sure whats after that, or what fellowship is all about.

Also, ffp, are you maintaining a social/family life through all this training? :eek:

Regardless, I am truly blown away by your dedication and would gladly accept any pointers. ;)

[Ian Wong]

Thanks Ian, great to hear a radiology perspective.

What is the certification process for cardiac imaging in the US? I have a couple of friends (cardio fellows) who are paying exorbitant sums to head down to the states for ~1 week courses where they can apparently obtain level 2 certification in CT angio or nuc.

At this point, there is no one clear certification process, as far as I know. The American College of Radiology has put out its recommendations. There's a new society called the SCCT (http://www.scct.org/) (Society of Cardiovascular Computed Tomography). The secondhand word on the street is that it is a society dominated by cardiologists as a mechanism to lend credence to their interpretation of cardiac imaging. I believe that the certification process through this society is significantly more lenient than through the ACR.

This is not dissimilar to Neurology forming the American Society of Neuroimaging (http://www.asnweb.org), as a "backdoor" way of getting credentialling to interpret head CT's and MRI's. They get credentialling through this society, and their numbers are way less than what a neuroradiology fellow would accomplish during a typical Neuroradiology fellowship. They call themselves "neuroimagers", because they cannot refer to themselves as neuroradiologists.

True neuroradiologists as a whole belong to the American Society of Neuroradiology (http://www.asnr.org), a totally different society.

You cannot learn any of this stuff in a week. It's simply not possible. Cross-sectional imaging is something that literally takes years to master. When you see a radiologist fly through a CT scan, and start rattling off details, while stopping at exactly the 2-3 slices out of 225 images that show the important pathology, that's literally the product of knocking through tens of thousands of these CT's during residency and practice. It's no different than watching an EP guy blow through the EKG that was stumping the cardiology fellow.

The fact that we have fellowships in just chest imaging, or mammography, or abdominal imaging, (think about that, a career in chest radiologist is basically reading just CXR's and chest CT's as there's minimal thoracic MR and U/S out there for physics reasons), speaks volumes to just how complex the anatomy and pathophysiology is that we work with.

The average chest radiologist will typically outperform a respirologist on thoracic imaging. The same is true of a neuroradiologist versus a neurologist, or a pediatric radiologist over a pediatrician. We literally spend all our time with these images. We know the anatomy and pathology from the imaging standpoint, because it is what we do on a daily basis. If you are looking for an anatomy lesion, we are the best placed to find it, and describe it.

It's actually insulting to think that a physician could demonstrate technical mastery in something as complex as cardiac imaging through a week-long course. Typically, it's just an empty certificate (not unlike the SCCT or the American Society of Neuroimaging), which looks good on the wall, and gets you through the hospital credentialling committee.

It's actually funny that this topic came up, because this morning I was at a multi-disciplinary Respirology case conference. It was the respirologists and several of the chest radiologists and us residents. One of the resp staff was showing a case, and put up two chest CT images. Clear as day were multiple bilateral pulmonary emboli. All of us radiology residents made the findings in 2-3 seconds. Several of the respirology fellows and even one of their staff couldn't see it until we pointed them out to them. Now, those guys are absolutely light-years ahead of me in actual patient care issues, but if you are looking for an anatomic abnormality on an imaging study, then I believe that my specialty is best-placed to find it. It's what I do every day. Particularly if you give me good clinical history, so that I can tailor my report to answer your clinical question.

It reminds me of our anaesthetists, who take a WEEKEND course in transesophageal echo and then come back thinking they are competent to perform and interpret them... we've had nothing but trouble with that.This is no different than our ER docs trying to dabble with ER ultrasound. It's a huge mess to try to over-read or redo an ER study, when they get in over their heads. It's really too bad, because turf wars are all about money, and have nothing to do at all with patient care. Radiology can be an uncomfortable specialty sometimes because imaging pays more than H&P's and consults. For this reason, almost every other specialty in medicine could make more money if they start doing imaging themselves, and so radiology finds itself constantly battling for turf against literally all other specialties.

OB wants to do OB ultrasounds, but only if they are elective, and are not done at night in the ER to exclude ectopics. Vascular Surgery wants all the dopplers, but again, only in the daytime, and not on weekends or overnights. Neurology is trying to muscle in on neuroimaging. GI docs are thinking about learning how to read virtual colonoscopy. Cardiology is busily trying to take over all cardiac imaging. Orthopods and ENT surgeons are buying magnets and CT scanners. ER docs are trying to do ultrasound themselves. etc, etc...

Someone told me that in order to work at a major academic centre in the US, you need a full length imaging fellowship... but many cardiologists who own their own heart institutes/practices have only the 1 week training. I am at a major academic center in the US, and I believe the two cardiologists who are doing cross-sectional imaging each have less than 1 year of formal fellowship. If I'm not mistaken, they both have a total of 6 months. Our main radiology guy did a year-long fellowship at MGH in Boston.

It's a little disconcerting to me that patients might not know whether the person reading their CT got their certification from a full length fellowship, a 1 week course, or a Cracker Jack box!Way back when I was an intern, I was told that the huge private practice cardiology group in the city was doing cardiac MR already. They had one guy who had done a fellowship of some sort, and he was "training" his partner how to read them on the job. I'm not sure how true that is, but it would be rather disconcerting if that were truly the case.

Maybe I'm just jaded thinking about all of the blood, sweat and tears involved in getting level 2 echo :PLike one of my favourite attendings in residency says constantly: "There is no learning without suffering." Knowledge doesn't come easy, and it takes a long period of training to get good at it. Even after all this time in radiology residency, even knowing that I have literally looked at more imaging studies than any other non-radiology resident, and probably most non-radiology staff in my hospital, I still feel like I've barely scratched the surface of my specialty. It's really a humbling process, as I appreciate just how much I still don't know.

Stuff like this is not meant to be Walmarted or commoditized through weekend courses and bogus certificates. In the US particularly, where money rules, unfortunately sometimes ethical behaviour gets pushed aside. I'm not naive enough to believe that this doesn't happen in Canada as well, but I hope and believe that it occurs to a lesser extent.

Ian

[e_is_hv]

Hey Ian and FFP,

Just wanted to thank you for your amazing and detailed posts. This forum is such an excellent resource, and I really appreciate picking your brains.

e_is_hv

[inspiring-curmudgeon]

Sorry to bring this thread back from the dead, but I was wondering if job prospects for interventional cardiology have gotten better currently. What is the lifestyle like generally? I've been told that the interventional lifestyle is killer, and you won't have much time to spend with family & friends. I'm interested in this field, but don't want to spend 7-8 years of post-graduate training to not have a job at the end of it!

[cheech10]

Lifestyle's about the same, not great but there are worse specialties. Job market is brutal right now, but that's the case with a lot of subspecialties in major urban centres.

[boanssi]

I have a question for cardiology residents: I have an interest in this field but, unfortunately, my hearing is a little poor for someone my age (I'm in my twenties). Is this a deal-breaker?

[boanssi]

I have a question for cardiology residents: I have an interest in this field but, unfortunately, my hearing is a little poor for someone my age (I'm in my twenties). Is this a deal-breaker?

So...noone? :(

[cheech10]

Cardiac auscultation is mostly recognition and interpretation rather than sound volume. There are electronic stethoscopes that amplify the sound to help with your issue. Some can also do waveform analysis if downloaded to a computer.

Also, the value of auscultation is less than it was in the pre-echocardiogram era. Most significant findings are verified by echo these days.

[boanssi]

Thank you!