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. Our third and final installment of this series focuses on subspecialization.

Do fellows need to have an idea of what they want to subspecialize in when they get started?

John Ryan (current fellow): I don’t think so. Most of us have not done catheterizations or read echos before starting fellowship, and not many of us appreciate what it means to be an EP or a heart failure doctor until the clinical training starts. Therefore, I think people should go in with an open mind. In fact, I feel it may affect the general training if one starts the fellowship with the intention of entering one particular area of cardiology.

Andy Kates (fellow from 1997 to 2001): Many clinical fellows come in with their long-term plans already in place (heart failure, EP, interventional) because of exposure (albeit somewhat limited at times) during their residency. While quite a few stay the course, others change focus during their fellowship as they see the various areas of cardiology in a different light than they did during residency. That is one of the reasons why the experiences of the first clinical year are so diverse and our fellows rotate through every (or nearly every) area of cardiology.

James de Lemos (fellow from 1996 to 1999): I agree with John and prefer that fellows not come in “hard wired,” because it leads to closed minds. I want the fellows to treat every rotation as if it might be their future calling.

What if there are rotations you’re not good at?

Ryan: One of the biggest struggles is the procedural aspect of cardiology. We typically go through medical school and residency being very cerebral and administratively oriented. Cath requires a new hands-on skill set, and I feel that the procedures we do during residency don’t prepare us for this (putting in a femoral venous line is nothing compared with getting the JR-4 to turn into the RCA under fluoro). Cath requires all of your senses, and I found it demoralizing when I struggled. The most important thing is not to avoid these tough rotations but to work extra hard during them. Getting to spend time in the cath lab is a privilege. A few years from now when we are out of fellowship and in our subspecialties, we won’t have the opportunity to work with teachers in the lab or learn our skills under supervision. Spending a couple of extra hours in those first few weeks practicing with the manifold or patiently “clocking” a JL-4 catheter inside and outside the body will pay off. It will make you a lot more comfortable and confident on-call, as well as help you feel more like a card-carrying cardiologist with skills that set you apart from all the other specialties.

Kates: It is interesting to see in which rotations different fellows excel.  Although there are always a few fellows who seem able to handle any rotation equally well, most are drawn to one area or another — usually related to the reason why they chose cardiology in the first place.  While that aptitude may be most obvious in the procedural areas, it may be equally apparent in other areas: the consultative cardiology realm, where interactions with patients and various clinical services requires a unique skill set; and in research, be it basic science, translational, or clinical research, where a certain creative mind-set is essential to asking — and answering — questions.

I agree with John that our role as PDs is to guide trainees to where their natural strengths are, but also to encourage fellows to reach higher and realize that hard work helps to build strengths as well.

de Lemos: We all have strengths and weaknesses, and some things just come easier or harder for different people.  I agree with John that this is most obvious on procedural rotations, but we also see it with interpreting images and dealing with complex data on cognitive rotations. It’s important use fellowship to not only find out what areas of cardiology you like the best, but also those that you have the most natural aptitude for. In general, our job as program directors and attendings is to provide honest feedback to fellows about skills and talents in particular areas, to help guide them toward a career path that matches their natural talents. Having said that, I believe that “natural talent” with your hands is not as important to procedural subspecialties as it was a few decades ago, given maturing of the fields and improvement in technology.

Even on procedural rotations, your attendings will care much more about your professionalism, your detailed workup of patients, and your effort than they will about whether you have “great hands.”

What are your thoughts about the challenges of subspecialization within a cardiology training program? And please also share what you thought of this three-part “advice” series.