Pursuing Cardiology As a Medical Student/Resident

As an Early Career blogger for the AHA, I wanted to write my final blog post on advice for those interested in pursuing cardiology. My interest in cardiology began during my first year of medical school, and now as I am applying to become a fellow, I wanted to look back at the last 7 years.


Medical school

As a medical student, it can be difficult to know what field you would like to pursue. Although some may know from the beginning what they would like to specialize in, the majority of students must use their time during their clinical years to explore different fields. Given this, I would advise students to focus on getting a good background in all aspects of medicine during medical school. Take as much in from your exposure to each field. Do well on your boards, take ownership of the patients you see and read as much as you can.

So as a first or second year how can you know if cardiology is a field you should consider? Well, what made me interested in the field during those years was the physiology behind the mechanics of the heart.  It made intuitive sense. The time I spent reading Lilly’s Pathophysiology of Heart Disease did not feel like studying. This inspired me to sign up for electives in cardiology later on in medical school. During third and fourth year, rotating on a cardiology consult service or a CCU service can help you see the day to day life of cardiologist. It exposes you to the common consults and admissions in the field. It also allows you to get to know the type of personalities in cardiology. If you are interested, get involved in research projects.


Internal Medicine Residency

In the beginning of my residency, my advisor told me that before one could become a great cardiologist, they must become a great internist. This is something that I heard echoed by cardiology program directors during this past year’s AHA Scientific Sessions. A passion for patient care and an understanding of the intricacies of internal medicine are paramount in the path of a future cardiology fellow.

Be a good citizen in your program. Complete all your administrative duties on time. Be the one that chiefs can rely on when scheduling difficulties occur. Residency is not just about being smart but being reliable and hardworking. This makes you stand out.

While on the wards, incorporate the use of ultrasound in your daily practice. Try and volunteer for procedure and make it a goal to become comfortable with central and arterial lines.

Depending on your interests in cardiology, as a medicine resident it is worthwhile to get involved in a research project. It is important to truly have a passion for the research topic you decide to study. Whether it is because a patient you saw was affected by what you are researching, or if you have background in that topic, it is important to have a connection with the research topic. This is what drives you to spend your time outside of the hospital working on the research project. Attempting to work on a project in the name of “just having research” is a recipe for burnout and you will likely not complete the project.

Show case your research either through presentations at the AHA Scientific Sessions poster session or the American College of Cardiology meeting. Recognize that the deadline for abstract submission for these conferences are months before the meeting. Besides presenting, networking and sitting in on lectures important topics in cardiology. It is inspiring and will further your aspiration to work hard.

Finally, make sure to begin working on your application, specifically the personal statement early.


What was your experience applying to cardiology?



What Is A Good Doctor?

Before beginning medical school, I believed that the best doctors were those who were geniuses, similar to the fictional Dr. House. They would walk in to a patient’s room, ask one or two questions, and immediately diagnose them without a sense of doubt. They would then walk out with a smug look as they told the team the correct treatment which ultimately saved the patient’s life. They remembered esoteric medical facts that solved mystery cases, leaving everyone else on the medical team in awe.

The more I go through medicine as a trainee, however, I am starting to realize the following: You will save more lives by being thorough than by trying to be a genius.

The best doctors chart checks their patients fully before seeing them. They read every note.  They review each lab and chase down every abnormality regardless of whether or not it is the patient’s primary problem. They read every sentence in an imaging report to make sure nothing is missed. When they interview a patient, their HPI and review of systems is exhaustive.

They go a step beyond by remembering personal facts about each patient that they see. They comfort patients when there is doubt, and they inspire their trainees to be better and spend more time on their craft. They know when the risks and harm of invasive procedures outweigh the potential benefits. They do not see time as a boundary and focus their effort on addressing every patient’s medical and psychosocial care.

An attending once told me, “The only factor that will remain the same between who you are now and who you will be 5 years from now is your work ethic. Experience is always going to make you better and build on your knowledge. However, it’s how thorough you are that is going to make the difference.”



POCUS: The Next Stethoscope

The invention of the stethoscope in the 1800s was a milestone in medicine. It revolutionized how physicians assessed patients, allowing for quick diagnosis of life-threatening illnesses. Despite more than a century past, findings with the stethoscope continue to guide our everyday clinical decision making.

I believe that the next invention to make as big of an impact on the physicians physical exam is the point of care ultrasound, also known as POCUS.

While it is not new technology per se, the improved portability of the new ultrasound probes and the decrease in cost of the technology has made it more accessible for everyday use. Medical schools are starting to slowly introduce ultrasound use into their curriculum. I believe that within the next decade every medical student will begin to carry a portable ultrasound probes the way ophthalmoscopes were carried by physicians in the 1950s.

Already well established in the field of emergency medicine in the assessment of trauma patients, the modality is slowly beginning to be used on the wards by general practitioners. Whether it is assessment of undifferentiated shock, evaluating for causes of dyspnea, or evaluating heart function, real-time imaging with the ultrasound has the potential to guide differentials fast and with accuracy.  Instead of waiting hours or days for a formal transthoracic echocardiography or a chest x-ray, we can quickly diagnose life-threatening pathology such as tamponade or pneumothorax.

As with any skill in medicine, experience is the only way to improve in POCUS use. For those interested, the first step in learning how to use the ultrasound begins with learning how to find and assess the proper windows. From there, it is a matter of continuously using the ultrasound and correlating findings to prior formal imaging studies.



The Emergence of The Field of Cardio-Oncology

By 2026, it is anticipated that there will be more than 20 million cancer survivors in the US1. The increase in prevalence of cancer survivors is largely due to discovery and implementation of effective chemotherapeutics and radiation therapy.  This success has come with a price, however, as the same chemotherapeutics and radiation therapy that cure cancer also damage vital organs, such as the heart. A wide range of chemotherapeutics have been associated with coronary artery disease, pericardial disease, and thromboembolic disease. Radiation therapy may accelerate premature atherosclerosis through acute inflammation leading to early vasculopathy in irradiated regions. With the introduction of each effective novel agent in treatment that prolongs survival,  side effects may  affect patient health and quality of life.

These factors have prompted the newly published AHA Scientific Statement on the field of Cardio-oncology, focused on the vascular and metabolic ramification of cancer treatment2. Cardio-oncology is a rapidly growing field of study given the prevalence of cancer and the need for physicians to address the unique challenges of treatment of cardiovascular disease in the cancer population.

Similar to general cardiology, prevention is a vital aspect of the field of cardio-oncology. This is due to the fact that both detection and treatment of cardiotoxicity is difficult. Symptomatically, cardiotoxicity can take years to manifest with the use of certain chemotherapeutics  and detection of subclinical cardiotoxicity is challenging. Thus, monitoring and screening become the most effective ways to minimize risk of development of cardiotoxicity and vascular complications.

Care in the cancer population should be multi-disciplinary from the moment the decision is made on the chemotherapeutics/radiation cycle to be used in treatment. Oncologist, cardiologists, and primary care physician are a vital part of care and must work together to make sure patients are medically optimized before start of treatment regimens. This includes thorough risk stratification and analysis of the benefits of treatment modalities, which needs to be individualized. Demographic factors such as the patient’s family history, prior cardiac history, current exercise tolerance are important factors to consider. Identification of patients at high risk would allow for consideration of alternative therapy, closer monitoring, screening, and possibly prophylactic treatment with cardioprotective medications. These patients can be monitored closely and undergo regular screening for signs of ventricular dysfunction.

Cardio-oncology is an exciting field of study with many unanswered questions. As literature continues to grow, I hope that we can meet the many challenges of cancer treatment.



  1. Miller KD, Siegel RL, Lin CC, Mariotto AB, Kramer JL, Rowland JH, Stein KD, Alteri R, Jemal A. 2016. Cancer treatment and survivorship statistics. CA: A Cancer Journal for Clinicians 66 271–289.
  2. Campia U, Moslehi JJ, Amiri-kordestani L, et al. Cardio-Oncology: Vascular and Metabolic Perspectives: A Scientific Statement From the American Heart Association. Circulation. 2019;139(13):e579-e602.



People From All Walks of Life: A Narrative Medicine Piece On The Opioid Misuse Epidemic

The use of opioids for chronic pain is a difficult subject to approach with patients. In the 1990’s, these medications were used excessively for pain control. However, at that time, we were not aware of the addictive nature of these medications. Currently, roughly 130 people die every day due to opioid overdose and more than 11.4 million people misuse prescription opioids1. In 2017, the US department of health and human services declared opioid misuse as a public health emergency.

In the hospital, it is very difficult to have a one-to-one conversation with patients on how and why to stop opioid use. Sometimes, even despite our efforts to reduce opioid usage, we may find that patients are receiving medications through “other ways.”

The following is a narrative medicine essay on the topic of approaching opioid usage in admitted patients:

I started my day off on such a high note. All of the vitals were stable and all of the labs looked pristine. The social worker may have found placement for a patient, Mr. L, that had been on the service for 3 months.  This was going to be a productive day.

I picked up my white coat, my stethoscope, my list, and walked to the medicine nursing unit looking for Mr. L’s room. As I approached his door, I quickly spotted an alcohol dispenser and swiped my hand underneath it.

I quietly opened the door and walked into the private room. I saw Mr. L sitting on the side of his bed, watching the news. He had been readmitted to our service yesterday for shortness of breath, likely due to his heart failure. The oxygen was wrapped around his nose and he looked calm. As I walked towards him, his face turned towards me with a grimace.

Mr. L: “Why did you take away my Norco? I told you when I came in yesterday that I use them. This bed – it’s so uncomfortable and hurts my back.”

Me: “No ‘hello doc?’ No ‘how are you?’ At least let me have the first question,” I said as I sat down on the chair next to his bed. He chuckled for a second but went right back to his grimace.

Mr. L: “I’m sorry, doctor. I like you, but you young doctors don’t seem to understand. Everyone keeps on telling me my heart isn’t working right. I have so much trouble breathing and these fluid pills aren’t doing what they normally do. I’m dying, and yet, here you are, taking up an issue with my pain pills. You didn’t order them for me last time, and you’re doing it again.”

I thought back to my team’s daily rounds where Mr L’s opioid use was always mentioned in the problem list as “opioid misuse” and our plan was to repeatedly address our concerns with him.

Me: “Mr. L. Norco is the last thing you need right now with your breathing. It’s very addictive, and I don’t think ethically it would be right for me to start it.”

Mr. L: “This whole addiction business started with people partying back in the 70’s, shooting up heroin. You’re going to lump me into their group now? So, because of them I can’t be pain free while I sleep here?”

I take a pause.

Me: “I understand your frustration, but these medications are not meant to be used like this. There are patients with wide spread cancer who are using the doses you want. It’s just not reasonable.”

He looks down. I try to change the conversation. “So, how is your breathing? Getting better?”

I asked him all of my routine questions, completed a physical exam, and told him about how we needed to increase the dosage of the fluid pills we were using. He agreed with the treatment plan. I shook his hand and stood up to leave.

As I walked towards the door, I heard him say, “So, you’re not even going to discharge me with a refill?”

I turned back. “No, I’m sorry. You know, there are other medications set up that you can use if you would like to taper off of the Norco, but I can’t prescribe them. You have to see a pain management specialist.”

Mr. L: “Oh so another appointment for me to get to? You know what, that’s okay. I know people from all walks of life, if you catch my drift, doctor.” He looked back at the television.

There are many social factors that make opioid misuse a difficult issue to address in the hospital. As physicians, we must recognize that although we may not be prescribing these medications, patients may be receiving them through other avenues. The best method may be to do our best to set up a good physician-patient relationship and educate patients on the adverse effects of these medications.



  1. U.S Department of Health And Human Services,“What is the U.S. Opioid Epidemic?” https://www.hhs.gov/opioids/about-the-epidemic/index.html, January 22nd, 2019



Thiamine: An Important Nutrient to Consider in Treatment of Congestive Heart Failure

Thiamine deficiency is an uncommon nutritional deficiency in the developed world. The population most at risk in North America and Europe has been noted to be alcoholics with poor diets. This nutrient deficiency can manifest as several different syndromes, one of which is “beriberi.” Beriberi was first described by Dr. Wenckebach in the early 1900s who observed the presence of dependent edema, elevated venous pressures, and an enlarged heart in patients who had three or more months of a thiamine deficient diet, with recovery after thiamine administration. What followed years after were several case reports of alcoholics with signs of congestive heart failure who improved drastically with administration of thiamine.

Although today beriberi heart disease is a rare diagnosis, what it does show is that thiamine is an important micronutrient for the heart, and lack of thiamine can cause symptoms of heart failure.

Given that thiamine is excreted through the urine, another population that has been deemed to be at risk for thiamine deficiency is those on high doses of diuretics such as furosemide1. Interestingly, this population includes the difficult-to-control heart failure patients that we see on the wards every day. Biochemically, one study has shown that thiamine uptake in cardiac cells can be inhibited by furosemide2.

Yet, treatment of patients with congestive heart failure on diuretics with thiamine is not currently standard of practice.

Looking at the literature, there have been only two randomized double blind placebo controlled trials on thiamine use in patients with congestive heart failure: Shimon et al 19953 and Schoenenberger et al 20124. Both of these trials showed a statistically significant increase in left ventricular ejection fraction with the use of thiamine in patients presenting with symptomatic congestive heart failure. Granted, the ejection fraction only improved by 3-4% which we could say was due to echocardiography interpretation variability. However, being that thiamine is cheap and there is evidence that points towards its use as a medication in heart failure, should we institute it into our daily practice?

What do you think?



  1. Katta N, Balla S, Alpert MA. Does Long-Term Furosemide Therapy Cause Thiamine Deficiency in Patients with Heart Failure? A Focused Review. Am J Med. 2016;129(7):753.e7-753.e11.
  2. Zangen A, Botzer D, Zangen R, Shainberg A. Furosemide and digoxin inhibit thiamine uptake in cardiac cells. Eur J Pharmacol. 1998;361(1):151-5.
  3. Shimon I, Almog S, Vered Z, et al. Improved left ventricular function after thiamine supplementation in patients with congestive heart failure receiving long-term furosemide therapy. Am J Med. 1995;98(5):485-90.
  4. Schoenenberger AW, Schoenenberger-berzins R, Der maur CA, Suter PM, Vergopoulos A, Erne P. Thiamine supplementation in symptomatic chronic heart failure: a randomized, double-blind, placebo-controlled, cross-over pilot study. Clin Res Cardiol. 2012;101(3):159-64.




How Does An Intern Become Burnt-Out In Residency?

The transition from medical school to residency is abrupt, yet exciting. We begin the year so eager and enthusiastic. The rush of adrenaline as you place your first order… the validation you feel as the attending physicians agree with your plan… the first time you make the correct diagnosis in the ever-elusive morning report cases… all of it is new and challenging.  The patients refer to you as doctor and ask you questions about their care. The nurses ask if you can evaluate a sick patient because they want your opinion. You spend hours after sign-out making sure your notes are perfect, which your academic mind considers a daily writing assignment that you MUST ace every time. You try your best to read that article on UpToDate before you fall asleep. You are the first one to get to the hospital, and last to leave.

You have been given trust and responsibilities. You want to meet these expectations.

The first few months pass and you find a rhythm. The feelings of excitement fade and you begin to feel efficient. You start to recognize what you need to do to keep your attending physicians and the upper levels happy.  You are finishing your work faster than before.

You start to feel more comfortable, but little day to day things happen that change you without you even realizing it. A patient passing away, a picture of your family together for dinner without you, a burnt-out consultant yelling at you over an improper consult. When these things occur, you ignore them and try to move forward. You feel as though you have easily brushed them away, but in reality, they affect you.

January and February become the hardest months of the year. Burnout can present in many different ways. It can present itself subtly like having difficulty getting up in the morning to go to work. You may think to yourself, “this is normal, tons of people have a difficult time getting up in the morning.” Yet, it is like a stepping stone. Your lack of sleep turns into you finding nursing calls annoying. All of the time spent on documentation, hours spent in front of computers taking away from patient care begin to change how you view your work. The combination of working twelve hours a day and trying to learn more about the pathology you see becomes difficult. You may even find your work uninteresting. And yet, with all of that said, even though you are fully aware of burnout and have heard the term multiple times, you believe that what you are experiencing is normal.

The first step to tackling burnout is to recognize it. Self-reflection is an important aspect of residency, but at times, it is your friends and family that point out the subtleties of burn out. Once you have recognized it, then it is easier to track and find what exactly is causing you to feel stressed.

Have you experienced burnout? If so, how has your experience of burnout affected you?



Mentorship and Inspiration at Scientific Sessions

Life as a resident physician can be demanding at times. The long hours, the difficult task of cross covering multiple wards, and the emotional toll of caring for sick patients are all factors that can make residency a difficult road to travel.  It can be easy to lose sight of the bigger picture and in the process, your empathy. It is important to keep track of where you have been, and more importantly, who you want to become. This is why I believe that mentorship and inspiration play a critical role in medical training. A great mentor can guide you, can celebrate your victories with you, and also, pick you up when you are down. At the same time, inspiration helps you push through difficult times. As residents, we need to identify with and become inspired by those that have gone through the path we are on so that we may fight burnout.

With that in mind, I would like to make the plea to students, residents, and fellows at any level of training to attend the AHA Scientific Sessions next year. Here is why, given my experience this past year at AHA18:

First and foremost, walking into Sessions, you will feel connected to something larger than yourself. You will find thousands of people from different fields of study and walks of life in attendance who have traveled many miles in the name of their dedication to reducing the burden of cardiovascular disease and strokes. This part of the experience really changed how I viewed my own training as a resident, and I began to see my role in the bigger picture.

Second, Sessions provides an opportunity for professional development. Whether you are attending an activity in the Early Career Lounge, or watching a lecture in the main auditorium, you end up meeting influential clinicians and scientists at every turn. You learn more about the challenges they faced in their training, their work ethic, and their inspirations. I found that many had gone through the same uphill battles as me: balancing research and clinical duties, family and work, down to even grasping difficult concepts in cardiology. This resonated with me.

These face-to face interactions help you not only address your own challenges, but also plan out the next steps in your career. Whenever possible, I took the opportunity to discuss a research idea or career choices with the mentors I met at AHA. Whether they supported the idea or played devil’s advocate, they helped me view these ideas in a different way. At the same time, I was able to pitch in my experiences as a resident and a former medical student to help those going through training.

Setting aside time from clinical duties to attend conferences can at times be a difficult endeavor, but I believe that experiencing a national conference such as Scientific Sessions can aid your career. It will help you identify mentors, role models, and potential collaborators.



High Sodium Consumption: The Next Public Health Endeavor?

We hear it everywhere. “Don’t put too much salt on your food, it’s not good for you.” It is a statement that is so frequently said by doctors to their patients, by concerned family members to their loved ones, that it has almost become part of our culture. Off the top of my head, I can think of a dozen movies where the main protagonist gets the table salt taken away from them because they have high blood pressure.

With that said, as noted by the AHA’s “Common High Blood Pressure Myths” article1, adding table salt to your food is not the main culprit causing medical problems. It is the hidden sodium in our processed foods.

Recently, I took it upon myself to pay a closer look at my diet. Like many American, I eat out a lot. Given that most fast food restaurants are starting to note the calories within their food, I started to realize it was easy to keep up with the CDC-recommended calorie count of roughly 2,300 calories per day2. However, the one variable that always kept coming up high in my diet was sodium.

It’s not like I was eating hamburgers everyday either. I started to realize simple condiments pushed the sodium in my food to astronomical numbers. A serving of hot sauce, broth in my ramen noodles, even pickles, would cause my sodium intake to leap despite a low-calorie count. On restaurant menus, I always saw in small letters the warning that “guidelines recommend a 2,000 mg daily sodium consumption”, and next to it, I would find a food entrée that had twice that amount in a single serving. As a physician, I was recommending sodium restriction to all my patients as an easy treatment for their many comorbidities, and yet, I had a difficulty following my own recommendations. Sodium is everywhere and trying to keep its consumption in check is a challenge.

So why is high sodium bad?

Initially, clinicians attributed sodium’s harmful effects to its association with high blood pressure3. Multiple meta-analysis and randomized control trials have shown a strong positive correlation between high sodium intake and elevated systolic blood pressure. As we know, high blood pressure is associated with a myriad of health complications affecting the heart, kidneys, and the brain. Thus, given sodium’s relationship with the number one cause of cardiovascular related death worldwide, it would make sense that sodium restriction has become the first-line treatment for hypertension.

Yet, new research presented at this year’s AHA Scientific Sessions is suggesting that there may be more adverse effects associated with high sodium consumption than just its effect on blood pressure. During the “Cutting Edge in Cardiovascular Science” presentation at Sessions, Dr. Constantino Ladecalo of Weill Cornell Medicine presented evidence in mice studies correlating high sodium consumption to neurovascular and cognitive impairment in the absence of hypertension. Outlined in a paper published recently in Nature Neuroscience4, Dr Ladecola presented a molecular pathway that may connect the effect of sodium in the small intestine with reduced resting blood flow to the brain, leading to cognitive impairment. The “gut-brain connection” as so called by Dr. Ladecola, may be a new frontier in medicine.

While Dr. Ladecola and his team suggested that this molecular pathway may be a new target for prevention of cognitive impairment, to me, their findings reinforced the fact that we need to return to the basics in our treatment of cardiovascular disease: lifestyle changes and nutrition. Previous endeavors in public health have helped eliminate several illnesses that were common such as thiamine deficiency, so why not attempt the same with sodium? As the evidence builds against high sodium consumption, it may be time for us to take a more active look at how we can address it. Can we work together with major food distributors to reduce sodium in their food? Should chain restaurants inform consumers of the sodium value in their foods as they do with calories currently? I am not sure of the answer to these questions as they can be very difficult endeavors to focus on.

What are your thoughts on sodium?

  1. American Heart Association. “Common High Blood Pressure Myths” October 31, 2016 “http://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/common-high-blood-pressure-myths”
  2. Kotchen TA, Cowley AW, Frohlich ED. Salt in health and disease–a delicate balance. N Engl J Med. 2013;368(26):2531-2.
  3. Center for Disease Control. “Most Americans Should Consume Less Salt” June 11, 2018 National Center for Chronic Disease Prevention and Health Promotion , Division for Heart Disease and Stroke Prevention “https://www.cdc.gov/salt/index.htm”
  4. Faraco G, Brea D, Garcia-bonilla L, et al. Dietary salt promotes neurovascular and cognitive dysfunction through a gut-initiated TH17 response. Nat Neurosci. 2018;21(2):