Future of interventional cardiology/EP

[MilesDavisTheDoctor]

I'm a med student a little bit interested in cardiology as a career and was wondering what current EP and interventional cardiology docs thought about the future of the field and if they enjoy what they're doing.

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[timpview]

Interventional here. I think it sucks.

I wouldn’t do any job that has heavy call burden (cardiology) or night shifts (ER). Working nights/weekends gets really old and will take years off your life.

I wouldn’t do any job that was dependent on a hospital for survival in todays world.

Personally I would do either a surgical subspecialty (urology would be #1) or a super low risk, low stress outpt gig (rheum, psych, endocrine)

If I were to do cards again I would just do General in a big tertiary center type group (call 1-3 nights/month with no STEMI/arrests responsibilities).

 

[MilesDavisTheDoctor]

Isn't it cool cathing people and saving their lives? How many hours a week are you working?

 

[aafisahar]

Isn't it cool cathing people and saving their lives? How many hours a week are you working?

Yes it's cool for the first couple years then it's just time away from things you want to do.

 

[MilesDavisTheDoctor]

So what would you guys do if you could do it all over again? I'm surprised at this response lol. I thought a lot of interventional cardiologists liked their jobs.

 

[Rocher]

So what would you guys do if you could do it all over again? I'm surprised at this response lol. I thought a lot of interventional cardiologists liked their jobs.

EP is awesome, I'm an EP fellow but most all of the EPs I know like their job. I think it has much of what draws people to interventional but can have a much better lifestyle.

 

[aafisahar]

So what would you guys do if you could do it all over again? I'm surprised at this response lol. I thought a lot of interventional cardiologists liked their jobs.

I like cardiology and interventional, but the juice wasn't worth the squeeze for interventional, so I went general only. General is great. I would do it all over again; if I get bored, might do a CHF year, but we'll see how things go.

I personally didn't like EP and felt it was too complicated and esoteric to be worth pursuing. I also feel like EP loses a lot of general cardiology skills (tee, echo, nukes, hemodynamics).

 

[epeepsLI]

EP is awesome, I'm an EP fellow but most all of the EPs I know like their job. I think it has much of what draws people to interventional but can have a much better lifestyle.

Can you comment on what drew you to EP? I'm an incoming fellow, strongly interested in EP, don't think the timeline is a big deal for me (i.e. 2 years). The income differential for EP vs general has narrowed but to me is not a huge deciding factor. 2 of 3 letter writers were EP faculty, intellectually had a ton of fun on EP consults as a resident, trying to figure out whether the longer procedures are for me. Feels like the most complete specialty in all of medicine (play with AADs, devices with ICDs/PPMs, can place Watchmans if desired, ablations, consults, a touch of clinic). I also don't mind some general cardiology. Overall EP and the personalities it draws seem very cerebral. Tell me any reasons why I shouldn't do EP, just to play devil's advocate.

 

[cards67]

Most IC and EP I know love their specialty, but not always their job. Lifestyle, call burden, hospital dependency, etc. can vary greatly between jobs. But as mentioned, in the end its just a job. Future seems fine for either, depending what your expectations are.

 

[redlined1]

IC/Structural

Been in practice about 10 yrs

Would not do it again.

 

[deleted980918]

IC/Structural

Been in practice about 10 yrs

Would not do it again.

Is it the job or the specialty that you would not do it again?

 

[redlined1]

Is it the job or the specialty that you would not do it again?

The specialty

 

[MilesDavisTheDoctor]

why? structural seems cool af

 

[greatnt249]

why? structural seems cool af

I've stated this in other threads, not to be a downer, but to emphasize that one of the considerations you need to make when you choose a specialty is whether you're willing to put up with the most mundane day-to-day tasks that come along with the specialty for the next 30 or so years. The life of an interventional/structural cardiologist is NOT "show up and do cool cases all day every day."

 

[aafisahar]

why? structural seems cool af

it is cool, but structural is like 10-15% (at most) of what an interventionalist does, even less for most others. TAVRs are lucrative, so everyone is protecting their turf and newbies will need to put in time at their practice before someone will let them deploy. Mitraclips are complex and there simply isn't the volume unless you are throwing them in willy-nilly. No one should be doing watchmens given the paucity of data. Tricuspid clipping is brand new and I doubt it'll be shown to be efficacious. PFO closures are pretty niche and require good patient selection if you want to do good by your patients.

The trend I've seen the past 3 years is people ditching structural for peripheral because of how saturated structural is. Plus peripheral pays better with higher volume.

 

[deleted980918]

it is cool, but structural is like 10-15% (at most) of what an interventionalist does, even less for most others. TAVRs are lucrative, so everyone is protecting their turf and newbies will need to put in time at their practice before someone will let them deploy. Mitraclips are complex and there simply isn't the volume unless you are throwing them in willy-nilly. No one should be doing watchmens given the paucity of data. Tricuspid clipping is brand new and I doubt it'll be shown to be efficacious. PFO closures are pretty niche and require good patient selection if you want to do good by your patients.

The trend I've seen the past 3 years is people ditching structural for peripheral because of how saturated structural is. Plus peripheral pays better with higher volume.

Correct me if I am wrong, a TAVR is around 33-35 RVU and the interventionalist and the CT surgeon split the RVU. So essentially the CT surgeon gets paid the same amount for sitting in the control room?

 

[redlined1]

Correct me if I am wrong, a TAVR is around 33-35 RVU and the interventionalist and the CT surgeon split the RVU. So essentially the CT surgeon gets paid the same amount for sitting in the control room?

This is correct

 

[redlined1]

Also I agree with most of what timpview said regarding the pitfalls of IC

 

[deleted980918]

There’s is also a growing number of structural CT surgeon that did 1 year of SHD fellowship after CTS training. If they were to do a case, do they keep all 35 rvus?

 

[MaxPlancker]

How common are IC gigs that do not have the typical full-time schedule? For example, there are a couple of online postings for a week on week off IC gig, similar to hospitalist shift-work but wondering about the world of unadvertised jobs. How feasible would this setup be? Wondering if that would help with lifestyle and keeping away the gray hairs...

 

[timpview]

Those schedules are becoming more common but it’s not to tailor to a more “lifestyle” job.

It’s basically to try and cover STEMIs with the least amount of bodies as possible… because those jobs are usually 24/7 call for 7 days

Issue is NO ONE (admin, other docs, even other general cardiologists) understands what being on call for STEMIs are really like. So they’ll act like it’s just a Urologist taking call when in reality it’s more similar to a Trauma Surgeon.. and I would be very surprised if a trauma surgeon is on 24/7 for a week… plus most still require some work during the day, albeit not as extensive. But 1 or 2 bad nights and you’re just in survival mode…

That schedule seems to target the old timers. They live in their home after being fired by the more competitive jobs in their community. They then fly out or drive 3 hours to a hard to recruit place.

The old timers which are the enemy of corporate medicine thrive a little more in these environments. They’re not really as engaged so admin doesn’t have to listen to their two cents nonstop. They also don’t complain as much as they’re not doing a heavy clinic or busy in the Cath lab which is what typically drives them to speak out more. So they’re mostly checked out, collecting a paycheck while admin gets a warm body covering stemis. Old timers are use to the call, often have a slower daily pace which they like and are often by themselves at night (no kids, etc) so being on call is slightly more manageable. It’s basically structured locums with the benefit of a more familiar place.

I’m not familiar with a true shift-based schedule like ER/Hospitalist/critical care where they only require 8-12 hour shifts. Somehow our shift is not a shift unless if it requires 12 additional hours of high risk, high burden call with no time off the next day.

 

[timpview]

Isn't it cool cathing people and saving their lives? How many hours a week are you work

Isn't it cool cathing people and saving their lives? How many hours a week are you working?

For some, for sure. To me, not really.

I don’t view it as “saving” anyone. I view it more of hoping it goes well so I don’t have to watch or participate in someone dying .. or even worse could have done something different to prevent someone dying.. or even worse caused someone to die (even though that’s pretty rare for anyone).

So no one’s cheering on what’s suppose to happen when it goes well.. but when it goes bad than that’s not good for anyone .. whether that’s stuff that keeps you up at night over second guessing, your quality review committees, your peer review emails, your overall quality numbers delivered by admin in your group meetings, potential for lawsuit, state board stuff or job loss or increased job scrutiny..

Personally I don’t know many that “love” this job. I know that 700-800k and 8-12 weeks off can make many tolerate it or not regret doing it. The older generation who had patient, hospital, industry support and admiration seemed to have gotten more validation from their job (truly loved it) but obviously a lot of that is specific to the individual. I’m sure there are some that still “love” doing this.

 

[timpview]

Can you comment on what drew you to EP? I'm an incoming fellow, strongly interested in EP, don't think the timeline is a big deal for me (i.e. 2 years). The income differential for EP vs general has narrowed but to me is not a huge deciding factor. 2 of 3 letter writers were EP faculty, intellectually had a ton of fun on EP consults as a resident, trying to figure out whether the longer procedures are for me. Feels like the most complete specialty in all of medicine (play with AADs, devices with ICDs/PPMs, can place Watchmans if desired, ablations, consults, a touch of clinic). I also don't mind some general cardiology. Overall EP and the personalities it draws seem very cerebral. Tell me any reasons why I shouldn't do EP, just to play devil's advocate.

If EP doesn’t bore you to death or if you’re actually interested in trying to learn it, then personally I wouldn’t have too many concerns going into it.

The main thing that would get me is how morally opposed I would be in dealing with AF ablation. Afib is 70%+ of your practice and there a whole wide range of feelings when it comes to ablation from those that think it’s totally bogus with EP guys having no morals to those that think they’re doing a whole lot of good. I fall in the middle but I could quickly see being totally disenfranchised with recommending and performing a procedure with very questionable outcome data.. whether you’re talking cure vs the new en vogue endpoints of “reducing AF burden”..

Add to it ICD/pacers are pretty mundane as well.

But as of now, EP guys can crank out crazy high RVUs, only benefit from midlevels, can find jobs with basically no call and pull in 600-1.2M plus income… so lots of positives too

 

[Rocher]

Can you comment on what drew you to EP? I'm an incoming fellow, strongly interested in EP, don't think the timeline is a big deal for me (i.e. 2 years). The income differential for EP vs general has narrowed but to me is not a huge deciding factor. 2 of 3 letter writers were EP faculty, intellectually had a ton of fun on EP consults as a resident, trying to figure out whether the longer procedures are for me. Feels like the most complete specialty in all of medicine (play with AADs, devices with ICDs/PPMs, can place Watchmans if desired, ablations, consults, a touch of clinic). I also don't mind some general cardiology. Overall EP and the personalities it draws seem very cerebral. Tell me any reasons why I shouldn't do EP, just to play devil's advocate.

A few reasons I was drawn to EP:
- I enjoy solving the puzzles in EP, whether that be EKG interpretation, device troubleshooting, or intraprocedural diagnostics
- EP a great combination of cerebral and procedural work, combining an understanding of anatomy and physiology in a way few specialties are able to.
- The technology is cutting edge and the procedures are generally rewarding
- significant impact on patient's QoL. As opposed to what another poster says I think AF ablation outcomes are overall quite good. Sure there can be a high recurrence rate (even >50%) after a first procedure in patients with persistent AF, but that's a NNT of 2 for a significant increase in QoL and for paroxysmal AF patients it's even better.

I was also concerned about the potential for longer procedures, but in my experience if you're the operator the duration of the procedure doesn't matter a lot. I've done 4-5 hour VT cases where I was the primary operator and the time flew by because I was completely engaged with the work. Most procedures are <2 hours though.

Reasons you shouldn't do EP: If you don't like procedures and generally don't like EKGs/arrhythmias