Cardiology!

[e_is_hv]

Hey FFP, I have a question for you.

 

I'm a medical student right now at U of T. I did a double bachelors degrees in physics/electrical engineering. Right now I'm considering cardiology and radiology but can't make up my mind. I think Radiology is fascinating, but I'm not sure if I can spend the rest of my life just looking at pictures like a technician (no offense to the rads guys - we all know how important it is) - I really like using my clinical skills.

 

So I was intrigued about how there are fellowships in Cardiac Imaging (Echo, MRI/CT, SPECT/PET) for Cardiologists (specifically Ottawa has a ton). Why aren't the radiologists hoping up and down in anger about this? If you complete an imaging fellowship, does that mean you can bypass the radiologist, and order/interpret the kind of scans you're trained in? I'd like the ability to do that and see my patients (rather than spend all day interpreting scans for "patient" x).

 

Also, do you know if anyone does doulbe fellowships? Due to my background I also think Electrophysiology is fascinating and would consider doing both (as most programs are one year each). Thanks a lot, I really look forward to your response.

 

e_is_hv

[seeking1]

So wait...things are looking bad for interventional?

 

Also, how 'insane' is the interventional lifestyle?

[Ian Wong]

I think Radiology is fascinating, but I'm not sure if I can spend the rest of my life just looking at pictures like a technician (no offense to the rads guys - we all know how important it is) - I really like using my clinical skills.

 

So I was intrigued about how there are fellowships in Cardiac Imaging (Echo, MRI/CT, SPECT/PET) for Cardiologists (specifically Ottawa has a ton). Why aren't the radiologists hoping up and down in anger about this? If you complete an imaging fellowship, does that mean you can bypass the radiologist, and order/interpret the kind of scans you're trained in? I'd like the ability to do that and see my patients (rather than spend all day interpreting scans for "patient" x).

 

I am a PGY-5 in a US radiology program where we have both radiology residents and cardiology fellows reading out both cardiac CT and MRI in conjunction with our cardiac imaging attendings, half of whom are radiologists, and the other half of whom are cardiologists. We do both adults and peds cases, often with multiple cross-sectional studies each day.

 

I will give you the radiology-biased view, which is that I think our specialty is best placed to read both of these studies. Cardiologists have gotten heavily into the imaging game in the US because it is far more profitable to image a patient than it is to see them in the ER or in clinic. Echos, cardiac nucs studies, and caths all pay substantially greater than the admission and consult fees that are generated by seeing patients. It is these procedures that make cardiologists some of the highest billing physicians in all of medicine. To no one's surprise, chances are good that if you encounter a cardiologist, you will be getting imaged.

 

With both echo and nucs, cardiologists have been relatively protected from missing incidental findings, because both exams are completely focussed on the heart. In a similar vein, orthopedic surgeons don't really have much, if any increased liability when it comes to reading most plain films, since they are generally very strong at bone findings, and the rest of the plain film usually doesn't have enough soft tissue detail to alert you to incidental pathology.

 

Both CT and MRI, by their design, will image a much larger field of view, and it is in this area that there are often extensive incidental findings, particularly in the elderly and smoker/diabetes rich population that characterizes the highest-risk CAD group of patients. Lung masses, aortic pathology, adrenal lesions, renal cell carcinomas, hiatal hernias/distal esophageal carcinomas, and hepatic and splenic lesions often are in the field of view.

 

I still remember as an intern on my cardiology rotation watching a cardiac cath. Near the end of the procedure, I pointed out a rather sizable lung nodule which had been floating up and down with each patient respiration for the entire case. No one else in the room had noticed it.

 

On a different topic, cardiologists generally know very little about the protocols in generating cross-sectional images. Both CT and MRI are extremely complex in their imaging protocols. In order to repeatedly generate quality diagnostic images, a LOT of work goes on in the background to tweak sequences to optimize image quality and speed. These are things that radiologists are extensively trained in, and something that is not well addressed in any clinical specialty.

 

Additionally, a lot of the interpretive work is done using separate workstations and reconstructive software, to generate a manageable data set from the raw images. Without this post-processing work, you cannot interpret any of these studies. Radiologists have been using these workstations throughout the entirety of our training, as these features are often used in neuro-imaging, musculoskeletal imaging, and in all sorts of body and angio applications. Crossing-over to cardiac applications is easy for us. Cardiac CT and MRI require a very high degree of technical expertise, and you need this training and knowledge in order to do the exam justice.

 

As far as clinical correlation goes, I think for the bread and butter of cardiac CT, which will be in the evaluation of coronary artery disease and degree of stenosis, that radiology is more than adequately placed to do this. We have been grading stenosis and doing vascular interventions in Interventional Radiology for as long or longer than Cardiology has done coronary interventions. Similarly, we read all the peripheral vascular disease studies, both CT and MRI, as well as perform the angiographic studies. We are more than capable of evaluating the vascular anatomy and pathology on imaging.

 

In the same vein, cardiac MRI is often used as a problem-solving modality, with a fixed question being asked. For a focussed question, such as the gradient across an aortic coarctation, or quantification of the degree of shunting across an ASD, I think radiologists can easily perform these studies. I would agree that the average radiologist is not going to read an EKG at anywhere near the level of a cardiologist, but realistically, a lot of that clinical information is not available to the interpreting cardiologist anyway.

 

When I've seen cardiologists interpret nucs or echo studies, it is invariably a separate interpreting cardiologist from the individual who actually admitted the patient, and the clinical history supplied is typically just as useless as the clinical history supplied to radiologists for any of our imaging studies.

 

As ffp mentions, the turf war is primarily related to money. Cross-sectional imaging has the potential to drastically change the volume of diagnostic caths and therapeutic caths (hopefully decreasing the first, and increasing the second). It also has the potential to supplant a lot of the echos and nucs studies that are currently being done, and may have significant implications for the management of certain lower-risk patients presenting to the ER with chest pain.

 

At the end of the day, I see cardiologists reading the bulk of the cardiac CT and MRI, as long as it remains profitable. As the individuals who control the patient flow, they can direct patients either to their own scanners in their offices/imaging centers, versus sending them to radiology-based scanners. If, as we are seeing in the US, imaging reimbursement gets cut to the point where it is no longer profitable to own a cardiac imaging center, you will see cardiologists abandoning the imaging. It's the same reason why GI has never tried to muscle in on barium enemas or upper GI's, and why breast surgeons don't try to read mammograms; the reimbursement for time isn't worth the money or liability.

 

I do think for the few radiologists who are doing fellowships in cardiac imaging, that there will be more than enough work available in the boomer-generation for them to be gainfully employed.

 

However, because of the presence of other high-demand and high-reimbursing radiology subspecialty fellowships (ie. MRI, MSK, and Neuro), cardiac fellowships are relatively wide open at this point. Few graduating radiology residents want to be trained in cardiac imaging knowing that we might very well lose the turf war, when instead you could be learning how to crank out a head MRI in 4 minutes, or a knee MRI in 2 minutes. The ironic thing is that this will then become a self-fulfilling prophecy and we radiologists will lose cardiac CT/MRI due to manpower issues.

 

If that does come to pass, I hope that at the very least that we won't be asked to read these things on call from the ER. That would be a horrifying thought since these studies are very work-intensive, requiring much more man-power than virtually any other form of cross-sectional imaging.

 

Ian

[seeking1]

For simplicity's sake, can someone make a general year outline for the path to cardiology and interventional cardiology?

 

What I'm understanding is something like:

 

x years at uni > 3-4 yrs med school > 2 yrs residency > ~6 yrs cardio (general)

 

and I still am not sure whats after that, or what fellowship is all about.

 

Also, ffp, are you maintaining a social/family life through all this training?

 

Regardless, I am truly blown away by your dedication and would gladly accept any pointers.

[Ian Wong]

Thanks Ian, great to hear a radiology perspective.

 

What is the certification process for cardiac imaging in the US? I have a couple of friends (cardio fellows) who are paying exorbitant sums to head down to the states for ~1 week courses where they can apparently obtain level 2 certification in CT angio or nuc.

 

At this point, there is no one clear certification process, as far as I know. The American College of Radiology has put out its recommendations. There's a new society called the SCCT (Society of Cardiovascular Computed Tomography). The secondhand word on the street is that it is a society dominated by cardiologists as a mechanism to lend credence to their interpretation of cardiac imaging. I believe that the certification process through this society is significantly more lenient than through the ACR.

 

This is not dissimilar to Neurology forming the American Society of Neuroimaging, as a "backdoor" way of getting credentialling to interpret head CT's and MRI's. They get credentialling through this society, and their numbers are way less than what a neuroradiology fellow would accomplish during a typical Neuroradiology fellowship. They call themselves "neuroimagers", because they cannot refer to themselves as neuroradiologists.

 

True neuroradiologists as a whole belong to the American Society of Neuroradiology, a totally different society.

 

You cannot learn any of this stuff in a week. It's simply not possible. Cross-sectional imaging is something that literally takes years to master. When you see a radiologist fly through a CT scan, and start rattling off details, while stopping at exactly the 2-3 slices out of 225 images that show the important pathology, that's literally the product of knocking through tens of thousands of these CT's during residency and practice. It's no different than watching an EP guy blow through the EKG that was stumping the cardiology fellow.

 

The fact that we have fellowships in just chest imaging, or mammography, or abdominal imaging, (think about that, a career in chest radiologist is basically reading just CXR's and chest CT's as there's minimal thoracic MR and U/S out there for physics reasons), speaks volumes to just how complex the anatomy and pathophysiology is that we work with.

 

The average chest radiologist will typically outperform a respirologist on thoracic imaging. The same is true of a neuroradiologist versus a neurologist, or a pediatric radiologist over a pediatrician. We literally spend all our time with these images. We know the anatomy and pathology from the imaging standpoint, because it is what we do on a daily basis. If you are looking for an anatomy lesion, we are the best placed to find it, and describe it.

 

It's actually insulting to think that a physician could demonstrate technical mastery in something as complex as cardiac imaging through a week-long course. Typically, it's just an empty certificate (not unlike the SCCT or the American Society of Neuroimaging), which looks good on the wall, and gets you through the hospital credentialling committee.

 

It's actually funny that this topic came up, because this morning I was at a multi-disciplinary Respirology case conference. It was the respirologists and several of the chest radiologists and us residents. One of the resp staff was showing a case, and put up two chest CT images. Clear as day were multiple bilateral pulmonary emboli. All of us radiology residents made the findings in 2-3 seconds. Several of the respirology fellows and even one of their staff couldn't see it until we pointed them out to them. Now, those guys are absolutely light-years ahead of me in actual patient care issues, but if you are looking for an anatomic abnormality on an imaging study, then I believe that my specialty is best-placed to find it. It's what I do every day. Particularly if you give me good clinical history, so that I can tailor my report to answer your clinical question.

 

It reminds me of our anaesthetists, who take a WEEKEND course in transesophageal echo and then come back thinking they are competent to perform and interpret them... we've had nothing but trouble with that.

This is no different than our ER docs trying to dabble with ER ultrasound. It's a huge mess to try to over-read or redo an ER study, when they get in over their heads. It's really too bad, because turf wars are all about money, and have nothing to do at all with patient care. Radiology can be an uncomfortable specialty sometimes because imaging pays more than H&P's and consults. For this reason, almost every other specialty in medicine could make more money if they start doing imaging themselves, and so radiology finds itself constantly battling for turf against literally all other specialties.

 

OB wants to do OB ultrasounds, but only if they are elective, and are not done at night in the ER to exclude ectopics. Vascular Surgery wants all the dopplers, but again, only in the daytime, and not on weekends or overnights. Neurology is trying to muscle in on neuroimaging. GI docs are thinking about learning how to read virtual colonoscopy. Cardiology is busily trying to take over all cardiac imaging. Orthopods and ENT surgeons are buying magnets and CT scanners. ER docs are trying to do ultrasound themselves. etc, etc...

 

Someone told me that in order to work at a major academic centre in the US, you need a full length imaging fellowship... but many cardiologists who own their own heart institutes/practices have only the 1 week training.

I am at a major academic center in the US, and I believe the two cardiologists who are doing cross-sectional imaging each have less than 1 year of formal fellowship. If I'm not mistaken, they both have a total of 6 months. Our main radiology guy did a year-long fellowship at MGH in Boston.

 

It's a little disconcerting to me that patients might not know whether the person reading their CT got their certification from a full length fellowship, a 1 week course, or a Cracker Jack box!

Way back when I was an intern, I was told that the huge private practice cardiology group in the city was doing cardiac MR already. They had one guy who had done a fellowship of some sort, and he was "training" his partner how to read them on the job. I'm not sure how true that is, but it would be rather disconcerting if that were truly the case.

 

Maybe I'm just jaded thinking about all of the blood, sweat and tears involved in getting level 2 echo

Like one of my favourite attendings in residency says constantly: "There is no learning without suffering." Knowledge doesn't come easy, and it takes a long period of training to get good at it. Even after all this time in radiology residency, even knowing that I have literally looked at more imaging studies than any other non-radiology resident, and probably most non-radiology staff in my hospital, I still feel like I've barely scratched the surface of my specialty. It's really a humbling process, as I appreciate just how much I still don't know.

 

Stuff like this is not meant to be Walmarted or commoditized through weekend courses and bogus certificates. In the US particularly, where money rules, unfortunately sometimes ethical behaviour gets pushed aside. I'm not naive enough to believe that this doesn't happen in Canada as well, but I hope and believe that it occurs to a lesser extent.

 

Ian

[e_is_hv]

Hey Ian and FFP,

 

Just wanted to thank you for your amazing and detailed posts. This forum is such an excellent resource, and I really appreciate picking your brains.

 

e_is_hv

[inspiring-curmudgeon]

Sorry to bring this thread back from the dead, but I was wondering if job prospects for interventional cardiology have gotten better currently. What is the lifestyle like generally? I've been told that the interventional lifestyle is killer, and you won't have much time to spend with family & friends. I'm interested in this field, but don't want to spend 7-8 years of post-graduate training to not have a job at the end of it!

[cheech10]

Lifestyle's about the same, not great but there are worse specialties. Job market is brutal right now, but that's the case with a lot of subspecialties in major urban centres.

[boanssi]

I have a question for cardiology residents: I have an interest in this field but, unfortunately, my hearing is a little poor for someone my age (I'm in my twenties). Is this a deal-breaker?

[boanssi]

I have a question for cardiology residents: I have an interest in this field but, unfortunately, my hearing is a little poor for someone my age (I'm in my twenties). Is this a deal-breaker?

 

So...noone?

[cheech10]

Cardiac auscultation is mostly recognition and interpretation rather than sound volume. There are electronic stethoscopes that amplify the sound to help with your issue. Some can also do waveform analysis if downloaded to a computer.

 

Also, the value of auscultation is less than it was in the pre-echocardiogram era. Most significant findings are verified by echo these days.

[boanssi]

Thank you!

[K-Dhillon]

I want to be a Cardiologist, but I have few questions. I know that first I have to get the bachelor of Science degree, then pass the MCAT exam, then 4 years in medical school, then 3 years in internal medicine and finally 3 years in fellowship. But I don't want to go US to study because I cannot afford to go to Stanford University. I know that I can apply for scholarships, but I dont wanna get my hopes up. I have been always been good in studies, I would say even if I dont study, I get A's. There is alot of competition in my school so that is why I dont want to just rely on scholarships. Does anyone know any good universities or colleges in CANADA that have really good Cardiovascular education and training? Plus the reason I dont want to go to US is because I dont know anyone there and I don't want to leave my parents behind. I really need help on this topic....Please help

[rmorelan]

I want to be a Cardiologist, but I have few questions. I know that first I have to get the bachelor of Science degree, then pass the MCAT exam, then 4 years in medical school, then 3 years in internal medicine and finally 3 years in fellowship. But I don't want to go US to study because I cannot afford to go to Stanford University. I know that I can apply for scholarships, but I dont wanna get my hopes up. I have been always been good in studies, I would say even if I dont study, I get A's. There is alot of competition in my school so that is why I dont want to just rely on scholarships. Does anyone know any good universities or colleges in CANADA that have really good Cardiovascular education and training? Plus the reason I dont want to go to US is because I dont know anyone there and I don't want to leave my parents behind. I really need help on this topic....Please help

 

ahhh those are some really early questions - where are you at right now? I am also not sure what the focus on Stanford is for? I mean there are a lot of very good schools other than Stanford of course, and more specifically Canada has many very good schools for Cardiology - of course that is at the residency level primarily for either country

[K-Dhillon]

I want to attend Stanford university but the cost is out of my affordable range. I thought that is a really good university. I want to attend a university in Canada, but I don't know which one. Currently I am in my final year of high school, and my school has told me that I have to start applying to universities as advanced early admission. I want to get my Bachelor of science degree from University of Manitoba and then move on to another place to attend Medical school. I have no clue which university I want to attend after getting my bachelor of science degree. I am really confused, because there are a lot of good medical schools related to Cardiology but I cant decide which one I want to attend.

[K-Dhillon]

http://www.ivyglobal.ca/mcat/med_schools_canada.asp

This is the website I thought would help me in finding a good medical school/univeristy, but there are so many options.

[rmorelan]

http://www.ivyglobal.ca/mcat/med_schools_canada.asp

This is the website I thought would help me in finding a good medical school/univeristy, but there are so many options.

 

ha - that won't help much because of the overall Canadian system. Unlike the US all the funding is pretty much government and tuition - which means per student most schools are around the same. It is really hard to be in terms of education alone exceptional then when everyone is working with the same resource level. They are ALL pretty good. Some schools have advantages in some areas but really those are relatively minor - particularly for something like internal medicine subfellowships etc.

 

The trick is to be accepted into anyone of them. Which is of course hard.

[K-Dhillon]

So should I apply to 3or 4 of them once I get my Bachelor of Science Degree? Do you know any website where I could find more about the universities in Canada. To get my bachelor of science degree, I was told to take BIOL 1020 (Bio 1), BIOL 1030 (bio 2), CHEM 1300, CHEM 1310, CHEM 2210, CHEM 22360, CHEM 2370, PHYS 1020, PHYSICS 1030, and few more biology courses, and English, and math courses. Btw I am currently doing university calculus, but I dont know what math courses I have to take. I don't know what courses I have to take to get my bachelor of science degree since every person I ask in the university tells me something different. At the same time the school guidance is no help. I think the best way to know is to ask a cardiologist but I don't know any cardiologist. Hopefully someone can guide me in the right direction.

[rmorelan]

So should I apply to 3or 4 of them once I get my Bachelor of Science Degree? Do you know any website where I could find more about the universities in Canada. To get my bachelor of science degree, I was told to take BIOL 1020 (Bio 1), BIOL 1030 (bio 2), CHEM 1300, CHEM 1310, CHEM 2210, CHEM 22360, CHEM 2370, PHYS 1020, PHYSICS 1030, and few more biology courses, and English, and math courses. Btw I am currently doing university calculus, but I dont know what math courses I have to take. I don't know what courses I have to take to get my bachelor of science degree since every person I ask in the university tells me something different. At the same time the school guidance is no help. I think the best way to know is to ask a cardiologist but I don't know any cardiologist. Hopefully someone can guide me in the right direction.

 

actually a cardiology wouldn't really be the best person for that as they would have been out of school for so long they no longer would likely know all the rules you need to follow - where are you doing your university? For starters for Canada no medical school requires calculus and it would be a rare one that requires english specifically I believe. That is a US thing. Broadly speaking at many schools you don't have a lot of prereqs or even any at all. Your degree could be in anything really.

 

Each school will have their own website you can look at. In ontario OMSAS is the central application services and has a handbook to all the Ontario schools. It does take a while to go through and learn what each school is looking for - one of the reasons for this forum in fact is to have understand those rules and how to best meet them.

 

Obviously what is required to actual graduate at your particular school's program is something they can best answer

[rmorelan]

Oh and your objective in the very competitive world of medical school apps would be to apply to as many schools as logically you would have a chance at.

[K-Dhillon]

So I should apply to as many Universities or medical schools I can after getting my Bsc, correct? But what courses should I take, I know that each Medical school has its own requirements, but I want to know the basic subjects I need to take to prepare myself of MCAT exam. The only thing I am confused about are the subjects, since there are so many Biology,Chemistry, and Physics realted courses. I posted a while ago the courses I will be taking. So the best bet would be telling the medical school about the courses that I am taking (to get the Bsc) and moving forward from there, right? Do medical schools consider extra-curricular activities. I volunteer at two hospitals and I am also part of a research team. I am also in sports, and school clubs (in most of them). I know that everyone has different opinions, but according to you, what are some of the best cardiology related medical schools in CANADA. You are probably like..this girl asks too many questions I just want to have my plans laid out so I don't fall behind later. It is going to be one heck of a ride to become a cardiologist, but I am determined to do it.

[rmorelan]

So I should apply to as many Universities or medical schools I can after getting my Bsc, correct? But what courses should I take, I know that each Medical school has its own requirements, but I want to know the basic subjects I need to take to prepare myself of MCAT exam. The only thing I am confused about are the subjects, since there are so many Biology,Chemistry, and Physics realted courses. I posted a while ago the courses I will be taking. So the best bet would be telling the medical school about the courses that I am taking (to get the Bsc) and moving forward from there, right? Do medical schools consider extra-curricular activities. I volunteer at two hospitals and I am also part of a research team. I am also in sports, and school clubs (in most of them). I know that everyone has different opinions, but according to you, what are some of the best cardiology related medical schools in CANADA. You are probably like..this girl asks too many questions I just want to have my plans laid out so I don't fall behind later. It is going to be one heck of a ride to become a cardiologist, but I am determined to do it.

 

there is a lot of questions - and more importantly I can tell by the posts that you don't yet know the best questions to even ask - that is normal of course as you are just starting The good news this forum overall and your school as well will extremely likely have a basic "this is how you get into medical school" talk - I give those actually at a couple of schools.

 

For a good start - look up the OMSAS guildebook - it gives you all the rules and what they are looking for in applicants. You have to learn what GPA is as that is out you are graded for admission. Absolutely ECs count etc. Read that and then we can be much more helpful focusing your plan.

 

In my opinion, in all honestly, it completely won't matter what medical school you go to - that may sound odd but really your medical school doesn't play a huge role in this. Cardiology for instance requires you to be accepted into residency after medical school in internal medicine and then after 3 years apply for cardiology. Internal medicine itself is not that hard to get into but what you do in those 3 years in internal med are very important to what comes next (ie getting cardiology).

 

Big centres for cardiology - well that is of course everywhere but Toronto and Ottawa in ontario spring to mind. Still your focus really should be in how to master the steps to getting into any medical school as that is the key step and really the hardest one in the entire process.

[K-Dhillon]

To be honest, my school guidance is no help. Basically they just dump all the information on us and expect us to know everything related to universities. I did all research myself by going to the university, but they were no help either. When I went to the university the guy photocopied me a page related medicine(that showed the courses to be taken for Bachelor of science degree). When I told him that I am going into medicine and would like to go to this school if I pass the MCAT exam, all he said was,"you should research online and ask those who are in this profession". That is why I have so many questions, but I was unable to briefly ask them. I am sorry I didn't clarify my questions. I am trying to this all by myself, for example finding information, talking to others for guidance. I have been to the university few times, and each time they tell me same thing or tell me to ask it in school. And when I go to school, they say the best way is to ask the university itself. I am fed up with going back and forth every week. That is why I joined this website to find more information so I could be directed on the right path

[h9i9j9]

I've heard rumours about 5-year direct entry (ie. no IM residency required first). Right now they're just that - rumours. We actually debated this at one of the internal med half days last year. I've also heard rumours about cardiology going to 4 years (AFTER completion of IM, so that would make 7 years total). IMO, this is WAY too much, especially if you still have to subspecialize on top of that.

 

Job prospects for cardiologists are generally great if you choose the right specialty. If you do general cardiology, you will be GOLD. If you do echo and have your own machine, you can set up shop anywhere and pretty much start printing money. Cardiac imaging (CT-angio, MRI, nuclear) are going to be very hot commodities in the near future. EP is also still an expanding field with lots of opportunities. The problem comes if you want to do interventional. Right now, jobs in Canada are scarce. Some people tell me I won't have a hope of getting a job if I hope to do interventional (I'd be finished in 2011), while others tell me that lots of new centres will open up (ie. interior BC) and that lots of people will be retiring. I don't know who to believe. I won't let job prospects influence my choice of specialty, though.

 

Has anymore heard more about a direct entry cardiology program? I looked around and couldn't find anything. Did the plans get scraped?

[A-Stark]

It doesn't exist.