CardioExchange Archive

With July just around the corner and a new generation of cardiologists about to start their training, the CardioExchange editors have asked the fellowship moderators to share their advice about how to face this exciting new challenge. We bring you that advice in a three-part series through the end of June. Part 1 focuses on the Learning Curve.

What advice do you have for feeling inexperienced, when you face that steep learning curve in the early days?

John Ryan (current fellow): Don’t be afraid to ask questions. I didn’t realize how little I knew about cardiology until I started fellowship. Although the skills I obtained during residency helped, nothing prepared me for that first call from the emergency department about a confusing ECG. The tombstone ECGs are easy to handle, as are the stone-cold normal ones. But the ones in between made me sweat. Senior fellows are an incredible resource here and will help you through the system until you start feeling comfortable and develop your own approach.

Andy Kates (fellow from 1997 to 2001): We don’t expect you to know everything.  That’s why it’s called a training program. I find myself constantly reminding fellows that we do not expect them to come in fully trained. That’s part of our job. We do, however, expect and encourage you to ask questions. You will be surprised at how much you actually know already — but another part of our job is to help you think of those items you had not considered.

James de Lemos (fellow from 1996 to 1999): Be an active learner. Bounce ideas off your attendings, senior fellows, and even co-fellows, but decide in your mind what you would do before you ask, so that you can gauge your decision-making and judgment against those with more experience. Jump right into your patient-care rotations — you won’t learn and you won’t get comfortable if you blend into the background. Finally, remember that we (the old folks) will get mad at you only if you don’t call when you should have. We never get mad if you call to run something by us or to check that you’re doing the right thing. So, in the beginning, always call for help when you’re not absolutely sure!

What about the first on-call echo that you have to do?

Ryan: On-call echos are super-stressful. First of all, there’s the physical strain of pushing the echo machine down the hospital corridors while fretting about the body habitus of the patient you are about to image. Second, the questions are often tough to answer, such as how to evaluate RV function for PE. When doing an echo, I send all family members and physicians out of the room before I start getting images. I find it stressful enough without someone looking over my shoulder asking, “What do you see?” I feel that doing an echo is akin to doing a consult, and I approach it the same way: Look at the primary data, see what extra information can be garnered from the echo images, and give your findings as an assessment of the patient as a whole.

Kates: You have backup. We do not expect — nor do we want — a brand-new first-year fellow to do a complete, accurate echo by him or herself. On-call echos tend to be performed on the sickest patients, often intubated and with poor windows. We want you to call for help. That said, one of the more rewarding aspects of cardiology training is being able to synthesize data obtained from the echo to aid in your decision-making process for a critically ill patient.

de Lemos: Deal with this by getting comfortable with your echo skills before you have to do it on call. Ask your program for an echo “boot camp” to teach you how to obtain and record basic images, rule out major emergent conditions such as tamponade, major new wall-motion abnormalities, etc. Sneak away from other rotations during slower times in the afternoon, and do echos on your classmates to build your skills. Remember, you only need to be able to do a few things with the echo probe at night — you don’t have to do the full study!

If you are about to become a cardiology fellow or are one now, what are your thoughts and fears about the learning curve of training? If your fellowship days are history, what’s your advice to the up-and-coming and the already-immersed younger folks?