January 26th, 2012
Follow the Fellows: Turning Points
William Kent Cornwell, MD, Kathryn Jesseca Lindley, MD, Aaron C. Earles, DO and Erica Sarah Spatz, MD, MHS
For our ongoing series at CardioExchange, “Follow the Fellows,” we have invited physicians from various cardiology fellowship programs to document their course through their training. In this post, the fellows describe the challenging moment that brought them to select cardiology as their specialty. You can read their earlier posts here, here, and here.
A Special Niche in Cardiology
by Kate Lindley, MD
I started residency with the intention of staying in general internal medicine. I liked the idea of preventive care and developing long-term relationships with my patients. I liked to see variety. I wanted a mixture of both inpatient and outpatient medicine. I was hopeful that medicine would be able to provide that to me.
My first night of call as an intern was in the CCU. I had never done an ICU rotation in medical school, I didn’t know the medical record system at my new institution, and I didn’t even know how to replete magnesium or potassium levels. Terrified may be the best word to describe me.
My first admission that night was a little old lady, probably 80 years old, who presented to the ER with chest pain — and an unknown coagulopathy. She had a “new” left bundle branch block (of course there were no previous EKGs in the system), and so she went to the cath lab for evaluation. Her coronary arteries were clean. That night, she developed a retroperitoneal bleed as a complication of her procedure. I spent hours holding pressure on her groin, and we transfused 28 units of blood products. She was intubated for respiratory failure. She ultimately went to surgery for vascular repair and, after a difficult course, was extubated and transferred to the floor. The next morning after rounds, I went home, exhausted, thinking, “I’m not sure if I’m ready for this! These people are sick!”
It was not the complication of a cardiac procedure that made the impression on me but, rather, my affinity for critical care medicine that I continued to discover throughout that month. Cardiac patients often come critically ill into the hospital, and in many cases, we have feasible therapies to offer them, and they actually recover and go home. Each year, my CCU month was without a doubt my favorite rotation, and I think this was ultimately what led me down the path towards cardiology.
The field offers me the opportunity to develop long-term relationships with patients and practice prevention (both primary and secondary), but also offers the chance to care for critically ill patients and actually see some good outcomes. I’m hopeful to find a balance between inpatient and outpatient medicine, and a mix of both procedures and prevention. It’s a tall order, but I’m confident that cardiology offers that niche.
Learning Not to Worry About the Hours
by Aaron Earles, DO, MS
Residency is filled with challenging moments. Most physicians while in residency encounter several cases that change our perspectives not just in medicine, but life as well.
My internal medicine training took place in rural Mississippi, where heart disease, diabetes, and obesity are common. I was fortunate enough to get exposure to cardiology early in my IM training, which definitely helped my decision to pursue the specialty. During my first year of residency, I had a good friend whose father came into the ER with a STEMI. The cardiologist I was rotating with asked if I would go to the catheterization suite and assist on the case. My friend’s father had a successful PCI and made a full recovery. Seldom in medicine do you see an almost instant improvement with treatment, but in cardiology it frequently is the case.
Intensive care rotations also proved to have daily challenging moments. Every day, I would need to call a cardiologist for assistance in cases ranging from rapid atrial fibrillation to WPW management. I learned tons of information from cardiologist during my ICU rotations.
On the flip side, seeing the long hours that cardiologists have to work weighed heavily on my choice. Those of you who have been on STEMI call know how unpredictable the work schedule can be. I can honestly say my love for cardiology outweighed the dread of those long hours. I have found in my first year of fellowship that the hours don’t seem as bad if you truly love the field you have chosen.
During my residency, I almost decided to practice internal medicine and not to pursue a subspecialty. You may hear many negative comments from specialists about why you should choose primary care as opposed to a subspecialty. My advice to residents in training who are trying to decide on a career path: select a field of medicine that you truly loved during your residency. If I had not chosen cardiology, I know that in 10 to 15 years I would have looked back and regretted not doing a fellowship.
Fellowship is rough, especially in the first year. I have been on call for every holiday this year except for Independence Day and Christmas. It is also tough to make the transition from a resident in IM to a fellow in a subspecialty. With great responsibility come great sacrifice and even greater rewards. If you honestly love helping people, then any field in medicine can be rewarding. If I had it to do over again, I would again choose cardiology.
The Field with the Most Data, But –
by Erica Spatz, MD, MHS
Our strength is our weakness. No, I’m not talking about how to answer that dreaded question on interviews. I’m referring to the field of cardiology. One of its strengths is the incredible rate at which new studies are conducted. No other specialty parallels cardiology in the amount of data constantly informing our practice. But, are we asking the right questions? Are we interpreting the findings of these studies correctly? How, and for whom, are these data applied, and at what expense? For me, the weakness of cardiology is the sometimes indiscriminate, sometimes self-serving motivation with which data are applied or not applied.
Residency seemed to magnify my ambivalence about the rapidity with which new cardiology data became available. I, like so many other wannabe cardiologists, imbibed each new study as it came out. I put to heart the acronym du jour, and with any luck, I got the study name correct, applied it to the correct patient population, and gave the proper amount of enthusiasm or skepticism to the findings and whether they should be adopted. Truthfully, while exciting, the whole exercise was stressful.
As a resident, I was riveted by studies like AFFIRM, COURAGE, and COMET. Sadly, however, I remember such details as who said what about the study, more than which patient prompted the discussion about the study. On January 19, 2005, as a second-year resident, I was rounding with my team on a patient with nonischemic cardiomyopathy. While discussing the evolution of indications for primary prevention of sudden death, leading up to the MADIT-II trial which demonstrated ICD placement to be superior to standard medical therapy for patients with ischemic cardiomyopathy (and thus not our patient), I was abruptly interrupted by my co-resident, also interested in cardiology. In a matter-of-fact way, he let me know that I was wrong…. Without a doubt, he assured me, the indications were for people with nonischemic heart disease as well. I cowered; now I wasn’t sure about the data. I no longer liked this game and suggested we readdress it the following day. As it so happened, I went home that night and opened my New England Journal of Medicine only to find the SCD-HeFT trial published that very same day.
I don’t remember what happened to the patient. Did she get an ICD? How did she do? I do not know. What has lingered after all these years, however, is that these wonderful, exciting cardiology studies are all-too-often utilized for the benefit of the physician and not of the patient. The good news is that once you recognize how often studies are misquoted, misinterpreted, or misapplied…you don’t have to beat yourself up about not remembering the acronym. On the flip side, however, only if we get the data right, can we hope to improve outcomes for the patient.
The Opportunity to Help Patients with Advanced Disease
by Bill Cornwell, MD
In residency, I spent a great deal of time deciding between pulmonology/critical care and cardiology as a subspecialty. Several moments throughout my training influenced my final decision. The first was in January of my intern year when my team admitted a middle-aged man with end-stage heart failure for an LVAD. In retrospect, this doesn’t sound like anything extraordinary (for anyone on a CCU or heart failure service, it likely seems like a typical case). However, this was my first time managing such a patient and witnessing firsthand the opportunities we have to intervene with critically ill patients with advanced disease.
Another “moment” during residency came with publication of the PARTNER trial in the New England Journal of Medicine, showing that cardiologists could intervene on patients with aortic stenosis who were poor surgical candidates. Who would have thought, even a few years ago, that such interventions would be possible? A third “moment” came when I reviewed a surface echo and cardiac MRI on a patient admitted for dyspnea, and we diagnosed noncompaction.
Outsiders often label cardiologists as plumbers (the interventionalists) and electricians (the electrophysiologists) — but the truth is, cardiology is a world in and of itself, with a broad spectrum of interesting diseases, and continues to evolve, offering new treatment options over time. Cardiology, more so than other subspecialties, incorporates the latest technological advancements into clinical assessments and treatment decisions. Considering the high prevalence of heart disease, society will always need cardiologists to care for sick patients, and cardiologists will have opportunities to make a significant and lasting impact on individual patients and on the field as a whole.