Top 10 Tips for Incoming Cardiology Fellows

Cardiology fellowship comes at you fast. Within the first day, you realize how much nuance exists within the field that you hadn’t been exposed to in internal medicine, and there are lots of patients whose care depends on those details. At the same time, you quickly come to appreciate how much of an impact you can make on a patient’s health and just how rewarding the field is. it’s a beautiful journey! In thinking back on the last two years, I wanted to share my top 10 tips and insights on fellowship aimed at incoming fellows.

  1. Learn from everyone. Nurses, techs, the cath lab team, sonographers, any staff with any clinical experience. There is often a sense you get when things aren’t right, and it takes a while to learn. These folks have developed it.
  2. It will take you at least 6 months to start to feel somewhat comfortable, a year before you think you got a hang of things, and that’s normal.
  3. Ask for help often. Key resources: senior fellows. They know everything, or they know who does.
  4. When you are on call, you are never alone. Get in the habit of communicating with your attending, even in the middle of the night. It’s the best thing for patient safety and your learning, and the attendings want it too.
  5. “Don’t guess when you can know.” The credit for the quote goes to Dr. Neil Stone, but the point is to get all the information you need (safely) and double-check the basics. The stakes are high in cardiology, so do the little things that prevent errors.
  6. Stay well outside of work. Family, friends, exercise, sleep, hobbies, whatever makes you you. These things are never more important than now. Burnout is real, prevalent, and painful.
  7. Meaningful learning happens through rote repetition in cardiology. Whether it’s in the cath lab or on echo, you will make insights through monotonous reps of seemingly routine studies/cases that you can’t make through any other means. Show up and dive in.
  8. It may take you a while to have the bandwidth to delve into academic pursuits outside of “just being a fellow” – that’s okay. Fellowship is hard.
  9. Recognize sick from not sick, and if someone is sick, move fast.
  10. When you consent a patient for a procedure, know the facts, and tell them. There is no such thing as a no-risk procedure. I will never forget this, after being involved in a case of a PA rupture during a straightforward right heart cath leading to a cardiac arrest. Make sure they know what they are signing up and consent is truly informed.

I would recommend going into cardiology to those who are interested 10 times out of 10. Congrats to those just starting out! I hope this list gives some pointers that help as you embark on your own journey in the field.


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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.”



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.