Pediatric cadiology vs IM cardiology

zedpol · Apr 23, 2006

Hey everyone,
I'm about to be heading into my 4th year of medical school and I'm still pretty undecided what I want to go into. I really liked peds, it was a great environment to be in and I enjoyed coming into the hospital every day. I have also enjoyed IM a fair amount, but my eventual goal (but keeping an open mind) is cardiology. I was wondering if anyone could weigh in peds cardio vs im cardio. Specifically in relation to a few things
1) Are there opportunities in peds to do this like EP, cardiac MRI, invasive cards and if not who does it?
2) I know congenital diseases are going to be a big part of a peds cardiologists practice, but what do they really do with it? Mostly refer to surgeons?
3) What kind of hours, call etc do pediatric cardiologists do?
4) How difficult would it be to get into peds cardio?
5) Would you have to be at a big hospital to practice peds cardio?
6) With the current emphasis in peds PCP what kind of salary do peds cardiologists make? My IM chief resident told me he was in a similar position but numerous people told him peds cardiologists earned in the 80-100k range, which really sucks since by the time I in a position to start paying off my loans they are going to be huge...just huge. It would be very difficult for me to have a family, house, and pay loans all at the same time. Wish it didn't have to be a consideration.

Ok, well that is all i can think of at the moment, I really appreciate any input even if it doesn't directly address my questions.

Z

deleted87716 · Apr 23, 2006

Good thread here; couple of years old, though.

14022 · Apr 23, 2006

zedpol said:
1) Are there opportunities in peds to do this like EP, cardiac MRI, invasive cards and if not who does it?
2) I know congenital diseases are going to be a big part of a peds cardiologists practice, but what do they really do with it? Mostly refer to surgeons?
3) What kind of hours, call etc do pediatric cardiologists do?
4) How difficult would it be to get into peds cardio?
5) Would you have to be at a big hospital to practice peds cardio?
6) With the current emphasis in peds PCP what kind of salary do peds cardiologists make? My IM chief resident told me he was in a similar position but numerous people told him peds cardiologists earned in the 80-100k range, which really sucks since by the time I in a position to start paying off my loans they are going to be huge...just huge. It would be very difficult for me to have a family, house, and pay loans all at the same time. Wish it didn't have to be a consideration.

1) There are subspecilty fellowships in EP, interventional, congenital heart disease (trained in kids and adults), echocardiography, cardiac icu, fetal, and probably a few more that I can't think of right now. You may not only practice EP or interventional, etc, especially if not in a very large center, but you will be the general peds cardiologist who does all the caths, for example, in most places.

2) Cardiologists do more with congenital disease than the surgeons in my opinion, at least at my hospital. The cardiologists are the first to see the kid and are required to make the diagnosis, which may be more diffciult than it seems. We learn a specific set of congenital lesions in medical school, but I didn't realize that most of the time lesions coexist and there is a wide spectrum of disease severity that can make it difficult to delineate. The cardiologist determines when the kid will need to see the surgeon. Just because a kid has a VSD, it doesn't mean the surgeon needs to close it. It may close on its own in a few months. If the kid has it for a long time or he is in heart failure and failing to thrive, only then is the surgeon needed. Even more severe lesions like tetrology of fallot may not need to see a surgeon. If the kid has minimal pulmonic stenosis and is adequately perfusing his lungs, he may not be significantly cyanotic to require surgery right away or ever. If he runs into problems as he grows, then the surgeon is consulted. And the cardiologists are actively involved in the post-op care of the kids and long-term follow-up. At my hospital, and I think it is like this at a lot of children's hospitals, there is only one heart surgeon, so it is difficult for him to be in the OR all day and still have time to manage the kids post-op. They rely on the cardiologists to do this.

3) Depends on the size of the group. At my hospital, there are 5 cards docs and they rotate call every 5th night. When they are on the inpatient service, they are there probably 7 or 8 am to 5 to 7 pm.

4) Peds cards is the second most competitve peds fellowship behiond ER. But over the last several years there have been more postions than American graduate applicants, with FMG's there are usually 1.1-1.2 applicants for each spot. But as peds continues to becomes heavier in research and as interventional becomes more popular, I think a lot more people may be going the peds route than the adult route with a consequent increase in the competitiveness of all peds fellowships, especially cardiology.

5) Congenital heart disease is the most common birth defect, affecting almost 1% of kids. Therefore, peds cards are needed in almost every hospital where they have a large birthing center or pediatrics patients, which are typically every academic hospital and many large community hospitals. If you want to subspecialize and do caths or EP or fetal, etc, then you likely will have to be in a large academic center.

6) 80-100K is a bit low, but probably realistic starting salaries in the top children's hospitals (Boston Children's, CHOP, Cincinatti, etc.). They are the highest paid peds specialists, but nowhere near that of their adult counterparts. However, as peds cards start to do more and more procedures in the cath lab, salaries will likely rise. But if you are looking for a high paying field, any area of pediatrics is not the best bet.

zedpol · Apr 23, 2006

scholes said:
1) There are subspecilty fellowships in EP, interventional, congenital heart disease (trained in kids and adults), echocardiography, cardiac icu, fetal, and probably a few more that I can't think of right now. You may not only practice EP or interventional, etc, especially if not in a very large center, but you will be the general peds cardiologist who does all the caths, for example, in most places.

2) Cardiologists do more with congenital disease than the surgeons in my opinion, at least at my hospital. The cardiologists are the first to see the kid and are required to make the diagnosis, which may be more diffciult than it seems. We learn a specific set of congenital lesions in medical school, but I didn't realize that most of the time lesions coexist and there is a wide spectrum of disease severity that can make it difficult to delineate. The cardiologist determines when the kid will need to see the surgeon. Just because a kid has a VSD, it doesn't mean the surgeon needs to close it. It may close on its own in a few months. If the kid has it for a long time or he is in heart failure and failing to thrive, only then is the surgeon needed. Even more severe lesions like tetrology of fallot may not need to see a surgeon. If the kid has minimal pulmonic stenosis and is adequately perfusing his lungs, he may not be significantly cyanotic to require surgery right away or ever. If he runs into problems as he grows, then the surgeon is consulted. And the cardiologists are actively involved in the post-op care of the kids and long-term follow-up. At my hospital, and I think it is like this at a lot of children's hospitals, there is only one heart surgeon, so it is difficult for him to be in the OR all day and still have time to manage the kids post-op. They rely on the cardiologists to do this.

3) Depends on the size of the group. At my hospital, there are 5 cards docs and they rotate call every 5th night. When they are on the inpatient service, they are there probably 7 or 8 am to 5 to 7 pm.

4) Peds cards is the second most competitve peds fellowship behiond ER. But over the last several years there have been more postions than American graduate applicants, with FMG's there are usually 1.1-1.2 applicants for each spot. But as peds continues to becomes heavier in research and as interventional becomes more popular, I think a lot more people may be going the peds route than the adult route with a consequent increase in the competitiveness of all peds fellowships, especially cardiology.

5) Congenital heart disease is the most common birth defect, affecting almost 1% of kids. Therefore, peds cards are needed in almost every hospital where they have a large birthing center or pediatrics patients, which are typically every academic hospital and many large community hospitals. If you want to subspecialize and do caths or EP or fetal, etc, then you likely will have to be in a large academic center.

6) 80-100K is a bit low, but probably realistic starting salaries in the top children's hospitals (Boston Children's, CHOP, Cincinatti, etc.). They are the highest paid peds specialists, but nowhere near that of their adult counterparts. However, as peds cards start to do more and more procedures in the cath lab, salaries will likely rise. But if you are looking for a high paying field, any area of pediatrics is not the best bet.

Thank you for the replies (to both of you). Scholes, i like your sig, rushmore is one of my favorite movies. I'm not so concerned about being in a high paying specialty, just more along the lines of being able to pay off my 1/4 million + of loans while still being able to send my children to college and owning my own home.

You mentioned peds cards doing increasing #s of procedures, what kind of procedures do they do? Sorry for the naive questions, i've been doing my best to find information everywhere I can. Trying to schedule a rotation at the begining of my 4th year. Any advice or recommendations would be hugely helpful.

Thanks,
Z

Daddydoc · Apr 24, 2006

Why not do a combined Peds/IM program?

14022 · Apr 24, 2006

Daddydoc said:
Why not do a combined Peds/IM program?

Combined Peds/IM cards fellowship? If you want to do this to be able to practice both peds and adult cards, this is an awful idea for several reasons.

1) 4 year med/peds residency + 5 year peds/adult cards fellowship = 9 years of residency work. This is an ungodly amount of time to only be making $40-55K per year.

2) Right now, I believe there are only 2 or 3 programs that offer this route.

3) This route is geared towards people very interested in congenital heart disease, with a goal of making these people specialized in taking care of adults surviving to adulthood with congenital heart disease. Adult cards trains very little (almost none) to learn any sort of abnormal anatomy (outside of simple septal defects or valcular defects), such that when adults with congenital heart disease, especially those that have been surgically corrected with shunts and conduits, present at an adult hospital, the peds cardiologists and peds echo techs at the affiliated children's hsopital will often be consulted to come over and take a look at the patient's heart.

4) Along the same lines as above, peds and adult cardiology are extremely different fields. Both are high volume fields as well. It is very difficult to practice both peds and adult cards, with the exception of congenital heart disease. So to go this route for the financial benefits of treating adults is foolish, especially if you have that much interest in adult cards to consider doing it in the first place. It would be a much better idea to simply go the adult cards route, avoid the 3 extra years of GME, and make the money like you intend.

One extra thought. Right now adult cards docs are making a killing. But keep in mind, most lucritive fields where new technology translates into big bucks (ortho, cards, radiology, ophtho, etc), once the new technology becomes standard of care, reimbusement usually takes a hit, so adult cards may not be as lucritive ten years from now, which will decrease the income gap between adult cards and their peds counterparts.

14022 · Apr 24, 2006

zedpol said:
You mentioned peds cards doing increasing #s of procedures, what kind of procedures do they do?

In the cath lab, the big procedures that are done at most hospitals include...

1) Rashkind procedure- dilating the PFO/ASD in lesions that limit outflow from one of the ventricles or have a parallel circulation (eg, hypoplastic left heart, transposition of great vessels) to allow adequate mixing of blood at the level of the atria.

2) Stents- stents can be placed in any artery that is narrowed. In adults, this is more likely to be coronary arteries. In kids, more likely to be a congenitally stenosed plumonary artery.

3) ASD closure devices- An amplatzer device can be placed within an atrial septal defect to block the defect.

4) Coiling- coils can be placed on arteries that should not be open, such as a PDA or abnormal collateral.

5) Balloon dilation- balloons can be used to dilate passages that are critically stenosed, such as a pulmonary valve or coarctation of the aorta.

New and exciting developments.

1) VSD closure- a similar device to that used for ASD's has been attempted to be used on VSD's, although with much more difficulty. Although it seems to work well for muscular VSD's, membranous VSD closure can often result in arrythmias and the device an also interfewre with the normal movement of the mitral valve. This is still experimental but anticipated to become standard of care for muscular VSD's in the very near future.

2) PDA stenting- if the baby has a ductal dependent lesion (meaning the PDA must be open to allow blood flow to the lungs or body (eg, hypoplastic left heart, critical aortic/pulmonic valve stenosis/atresia) then the ductus needs to be open. Usually PGE is given intravenously. There have been attempts to put a stent in the PDA instead of giving the medication.

3) Hybrid surgery- In my opinion, the most exciting development in congenital heart disease. In these procedures, the child is operated on in a special hybrid surgery suite which is a combination between a cath lab and standard OR. The surgeon and cardiologist work side by side in some cases to do both cardiac cath and surgery at the same time or within a short amount of time of each other. This method reduces the need for bypass in some cases and is safer for those kids who are high risk for bypass. This is VERY experimental and only done for a few procedures at a few centers across the country. I have read about it in the treatment of VSD's and hypoplastic left heart. Do a pubmed search and pull some articles if you are interested.

4) Fetal interventions- Boston Children's recently cathed a fetus. This is obvioulsy VERY experimental There is a no flow-no grow hypothesis in the development of heart disease. The amount of flow through a structure in utero determines the extent of development of a structure. For example, if there is mitral stenosis/atresia in utero, the LV and aorta will not develop as well. If there is aortic stenosis/atresia in utero, the aorta will not develop as well. If you can dilate stenosed sturctures in utero, you will increase the flow through the structure and hypothetically increase the development of the structures distal to the lesion. So how do you cath a fetus you ask? Very carefully. Since the placenta has sinusoids and capillaries, you obviously cannot go from mom to fetus. You have to insert a catheter through mom's abdomen, through the uterus, through the baby's chest wall, through the wall of the heart directly into the baby's heart. Something you don't learn until your second year of peds residency.

14022 · Apr 24, 2006

zedpol said:
Trying to schedule a rotation at the begining of my 4th year. Any advice or recommendations would be hugely helpful.

The best peds cards elective in my opinion is one where you do as much outpatient as possible. You will see a ton of kids, some healthy and some not so healthy. You will see a lot of kids referred for murmurs, so you will get very good at differenitating an innocent murmur versus a pathologic murmur, and then get good at narrowing down the possible lesions based on the type of pathologic murmur heard. This will help you immensely in residency and beyond. You will also get good at taking a history to make a differential for common outpt complaints, such as chest pain, syncope, exercise intolerance, etc.

Seeing kids in the ICU and cath lab and post-op are all interesting and educational, but not as high-yield for your intern year. If you can do both, it would be great. But if you have to choose an inpt elective vs outpatient elective, choose outpatient.

J-Rad · Apr 24, 2006

1. I think the salary ranges are generally in the high 180's to 220's on average. I believe there was a recent article in pediatrics that iterated that salary range for peds cards.
2. I would agree that doing med/peds followed by combined fellowship is a pathway for gluttons for punishment. While, yes, even the above salary range is below that of the average adult cardiologist, it is still respectable and, as stated if you are more procedurally oriented you will likely make more. If you happen to have an interest in adults with CHD you will have plenty of opportunity as a peds cardiologist and the choice to make that your field of expertise (the oldest patients I saw on my 4th yr. peds cards rotation were a 52 year old undergoing a diagnostic cath [by the peds cardiologist] to see if her ASD could be closed [unfortunately, no, that would have killed her quicker than her pulmonary HTN is going to in the next few years], and a 43 year old being evaluated for closure of her PFO [which was linked to her migraines-her neurologist sent her to cards]. And this was with a group that didn't have one dedicated Adult with CHD person).
3. Just an interesting sidenote about procedures: according to one of the guys at my hospital diagnostic caths are going more by the wayside as cardiac MR imaging is more routinely used; but overall that shouldn't substantially decrease the total number of available procedures.
4. I'll put in a recommendation for a place to do a peditric cardiology rotation based on my experience: Maine Medical Center in Portland, ME. It's a group of 5 cardiologists (three trained at Boston Children's, two at Ann Arbor) who are all very friendly and willing to teach when the opportunity arises (plenty of opportunities). There is one interventionalist, one electrophysiologist, one cardiac MR specialist, and the two others general cardiologists (although only the EP narrows mostly to his own field) so there is plenty to see variety wise (although at times you may just have a lower pt. census-esp. inpatient just based on luck). While I was there I got to see plenty of clinic patients and become much more comfortable with benign murmurs. I also got to see a good few post-op/post-cath patients in the PICU (and observe a Truncus repair-the peds CT surgeon is very nice as well and welcomes guests). They are the tertiary catchment area of northern New England and they are 5 of the 8 peds cardiologists in the catchment. I can give more info if needed.
5. Just an opinion: peds cardiac pathophys. is plain old more interesting than adult I-smoked-for-40-years-sat-on-my-butt-for-50-and-had-an-MI pathophys.

zedpol · May 13, 2006

Anyone mind weighing in on programs that are known for their cardiology programs? Two that i am specifically curious about are OHSU and Mayo.

Thanks,
Z

14022 · May 13, 2006

zedpol said:
Anyone mind weighing in on programs that are known for their cardiology programs? Two that i am specifically curious about are OHSU and Mayo.

Thanks,
Z

peds or adult cards? since you are in the peds forum, i assume peds.

i really do not know anything specific about either program, but i have never heard of either of them discussed among the top peds programs.

a few of the top programs i have heard of are boston children's, chop, cincinatti, columbia, and u michigan, but there are several other high volume programs throughout the u.s. that provide excellent training. typically, the higher volume of peds cardiac surgeries performed and the higher volume of complicated kids seen, the better the training experience.

heartdoc345 · Aug 6, 2007

It all depends on what you want...

If you're not sure which way you want to go, it may not be a bad idea just to do med/peds and decide later.

I am one of those gluttons for punishment who did med/peds and will soon start a 5-year combined med/peds fellowship. It was a hard decision, but the right one for me, since I want to run an academic adult congenital heart center someday and am very passionate about adult congenital heart disease. Since I'll be in academics, I said goodbye to the private practice salary a long time ago, but I'll have my own rewards in terms of research and personal fulfillment. Hopefully I'll make substantially more than a peds cardiologist since I will be certified at reading coronary CT/MRI (although that will probably entail another year of fellowship, for a total of 10, after med school).

If all you care about is money, don't do peds cardiology. Adult cardiology pays way more money. And peds cardiology is NOT the most lucrative peds subspecialty (NICU is because hospitals can legally rape parents of premature babies, or at least their insurance companies, even for "feeder/grower" babies).

If you want money and flexibility where you live and don't care much for congenital heart disease, then adult cardiology is the way to go. There are more jobs in adult cardiology, more patients, and much, much more money. In my city, we have about 30 adult interventional docs, but only 4 peds docs who work in the cath lab, and only 2 of them are interventionalists (one does transplant biopsies and one does EP).

If you want to do peds interventional, it would be difficult to guarantee a position at an academic center doing cath IN THE CITY WHERE YOU WANT TO LIVE. If you're not at a major children's hospital you probably won't be able to do much more than PDA and ASD closures in the lab. Adult interventional cardiologists and EP docs can easily command salaries > $300K, which is way more than a peds cardiologist would dream of.

You can probably make a lot of money doing private practice cardiology, but you likely won't get to do much in the cath lab, since the vast majority of the interesting cases are done at major peds hospitals with surgery backup. If you want to see dozens of patients in clinic every week and read tons of echos, you can make lots of money, but you may not get to use your hands much. Again, it depends on what you want out of your career.

If you like congenital heart disease, but also want to take care of at least some adult patients, I would recommend doing a med/peds residency to buy yourself some time to determine if you would rather do adult or peds cardiology. I'm biased, of course, but I think med/peds docs are much better trained for sick patients. You don't interview until your second-to-last year of residency, so if you do med/peds, you have 2 full years of rotations to make up your mind and get good letters.

I just went through the peds match and I can tell you for sure that peds cardiology programs love med/peds applicants because 1) they are overwhelmed with congenital adult patients and are more than happy to have a fellow who knows adult medicine 2) med/peds residents get much more hands-on ICU training during residency than their peds counterparts, 3) have already read many more EKGs than their peds counterparts, and 4) have more experience doing central lines and other critical care procedures than peds trained residents

In terms of competitiveness, adult cardiology programs are extremely competitive, and are more competitive than dermatology programs. The adult programs that interviewed me had 1 position for every 100 applications they accepted, and only extended interviews to about 10% of their applicants. The peds programs were more competitive than most other peds fellowships, but much less competitive than adult cardiology. Part of that may be self-selection since many more IM residents than peds residents specialize.

I agree that congenital pathophysiology is way more interesting than coronary disease. I could go on for a long time about why doing the combined program is right for me. It definitely isn't right for everybody. It's a long road, and there are very few places interested in combined training. Also, some cities that offer combined training are week on the adult side or peds side and strong on the other (much like many med-peds programs).

In terms of programs, I agree with the earlier list. I would recommend to talk to any academic pediatric cardiology who has trained at a large center, since in peds cardiology everyone seems to know everybody. Also, I would add Baylor to the list. Baylor has 5 peds cardiology fellows per year plus a number of 4th year fellows in cath / echo / EP. I was impressed when I interviewed there, although I chose not to go there. They have huge surgical volume and 4 entire stories of their 21-story children's hospital are devoted to pediatric cardiology. They also have an adult congenital program and have trained two med-peds fellows in a combined med-peds program.

oldbearprofessor · Aug 6, 2007

heartdoc345 said:
And peds cardiology is NOT the most lucrative peds subspecialty (NICU is because hospitals can legally rape parents of premature babies, or at least their insurance companies, even for "feeder/grower" babies).

Was this just a random comment or do you wish to expound upon this insight a bit? Note that hospital charges and physician charges are separate and that critical care codes are bundled.

Pediatric cadiology vs IM cardiology

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