Advice Needed – Choosing Between IC vs EP

[Mdinfo]

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Hi everyone, hope all is well.

I’m currently a cardiology fellow and at the stage where I’m deciding between Interventional Cardiology (IC) and Electrophysiology (EP). I enjoy procedures and am not particularly drawn to imaging (TTE/TEE are the least interesting to me), but I’m torn between these two paths. I’d greatly appreciate insights, especially from those actively practicing in these fields.

1. Interventional Cardiology (IC):
I like the subject — maybe because I’m more familiar with cath from prior exposure working with cardiologists in the cath lab. However, I have concerns about the call burden, the stress that comes with the schedule, and, most importantly, the interpersonal dynamics. I’m not sure if it’s just my current environment, but I’ve found IC personalities harder to deal with, with more hierarchy and politics than I’d prefer.

2. Electrophysiology (EP):
I find the lifestyle more favorable compared to IC, and the procedures are fascinating. The EP attendings I’ve met are also generally very approachable and respectful. My concern is that I’m not naturally strong in EKG interpretation or EP concepts — which I think is partly due to lack of exposure, but I do wonder if it’s a sign of a mismatch rather than just a knowledge gap.

I’d love to hear your honest perspectives on what life is like in each specialty, what you enjoy most, any real-world salary differences and what you’d do differently if you had to choose again

Thanks in advance!

 

[shouldigomd]

In my opinion the decision shouldn't be that hard as the two fields are very different. I am an IC so naturally biased that way. In terms of things that shouldn't really sway you one way or another... Both can be highly procedurally based and there are many EP docs that are in the lab more than IC's but this is highly variable depending on the job. EP vs IC personalities are overall different but obviously this is variable and not a reason to pick one over another. The procedures are so different. Insert my bias... A pacemaker is a glorified central line and this will be your bread and butter. I can't imagine anything more boring than moving leads around / mapping / ablating ... for hours. Obviously I am sure it is more engaging when you are the one doing it and processing the info. Some food for thought below about each.

EP
-lifestyle clearly better as there are no emergencies and often no call or weekends. More predictable.
-job market better as EP is in demand and overall also has the edge in terms of $$
-because EP is more in demand you can find more positions where you can do pure EP without general if that is something you want to do
-may not seem like a big deal but it is ... 2 year fellowship. I wouldn't worry about the EP learning part.



IC
-on call changes the lifestyle but how frequent depends on the group you join. Can be as miserable as every other day or as chill as 1 in 7 without general.
-emergency life saving situations. Some people love this some people don't. These situations are what i love most about my job. You have someones life in your hands.
-often times you have to take general call and nearly always do a significant amount of general cardiology.
-a more saturated job market which can also lead to more political drama
-there is more procedural versatility. Even without a dedicated structural year you can branch out to other procedures based on your interest. I didn't do a dedicated structural year but in addition to your typical IC stuff I do watchman, PFO/ASD closure, valvuloplasty, peripheral interventions, PE thrombectomy / lytics as a new interventionalist.

 

[Mdinfo]

In my opinion the decision shouldn't be that hard as the two fields are very different. I am an IC so naturally biased that way. In terms of things that shouldn't really sway you one way or another... Both can be highly procedurally based and there are many EP docs that are in the lab more than IC's but this is highly variable depending on the job. EP vs IC personalities are overall different but obviously this is variable and not a reason to pick one over another. The procedures are so different. Insert my bias... A pacemaker is a glorified central line and this will be your bread and butter. I can't imagine anything more boring than moving leads around / mapping / ablating ... for hours. Obviously I am sure it is more engaging when you are the one doing it and processing the info. Some food for thought below about each.

EP
-lifestyle clearly better as there are no emergencies and often no call or weekends. More predictable.
-job market better as EP is in demand and overall also has the edge in terms of $$
-because EP is more in demand you can find more positions where you can do pure EP without general if that is something you want to do
-may not seem like a big deal but it is ...

Thanks for your input. I do feel that the variety of procedures in EP is more limited compared to IC (and I do enjoy procedures in general). However, I’ve been told by both EP and IC attendings that no matter which field you choose, it eventually becomes routine and loses some of its initial “shine,” and then it’s more about what’s practical and sustainable.

One IC attending told me he regrets going into IC because he has very little time for family. Another mentioned that STEMI calls are stressful, and that he would be many times happier going back to EP — even though he never fell in love with EP, he still recommends it. Hearing these things from IC attendings honestly freaked me out, especially since I can’t imagine waking up for emergencies in the middle of the night for the rest of my career (though I realize that’s not completely avoidable in either IC or EP).

I’m not “in love” with EP, but I don’t dislike it either. It feels like a different language that I’d need to learn, and many EP attendings have reassured me that it’s just a matter of time before it clicks. I don’t want to choose one field and constantly look back wondering “what if.” I do like IC (maybe because I’m more familiar with it), but I don’t want the constant emergencies or the draining personality dynamics I’ve sometimes seen in that environment (with all respect to the many great people in IC).

On the other hand, EP tends to have a more pleasant work culture, and I could see myself working with that kind of team for years. While many EP cases can be managed medically if you wanted to, the specialty still has the advantage of a high degree of autonomy — few people outside EP truly understand what you do. The main drawback is that EP requires an extra year of fellowship, which matters since I have kids, but realistically one extra year is a small trade-off for a lifelong career.

 

[ihoop24]

In my opinion the decision shouldn't be that hard as the two fields are very different. I am an IC so naturally biased that way. In terms of things that shouldn't really sway you one way or another... Both can be highly procedurally based and there are many EP docs that are in the lab more than IC's but this is highly variable depending on the job. EP vs IC personalities are overall different but obviously this is variable and not a reason to pick one over another. The procedures are so different. Insert my bias... A pacemaker is a glorified central line and this will be your bread and butter. I can't imagine anything more boring than moving leads around / mapping / ablating ... for hours. Obviously I am sure it is more engaging when you are the one doing it and processing the info. Some food for thought below about each.

EP
-lifestyle clearly better as there are no emergencies and often no call or weekends. More predictable.
-job market better as EP is in demand and overall also has the edge in terms of $$
-because EP is more in demand you can find more positions where you can do pure EP without general if that is something you want to do
-may not seem like a big deal but it is ... 2 year fellowship. I wouldn't worry about the EP learning part.



IC
-on call changes the lifestyle but how frequent depends on the group you join. Can be as miserable as every other day or as chill as 1 in 7 without general.
-emergency life saving situations. Some people love this some people don't. These situations are what i love most about my job. You have someones life in your hands.
-often times you have to take general call and nearly always do a significant amount of general cardiology.
-a more saturated job market which can also lead to more political drama
-there is more procedural versatility. Even without a dedicated structural year you can branch out to other procedures based on your interest. I didn't do a dedicated structural year but in addition to your typical IC stuff I do watchman, PFO/ASD closure, valvuloplasty, peripheral interventions, PE thrombectomy / lytics as a new interventionalist.

Not to hijack OP's thread, but I have a few questions that may be pertinent to them as well:

What does your schedule look like? Are you in PP or academic?
How did you tap into peripheral stuff/PFO/watchman etc, without a structural year? Did you aim to do as many as you could during IC fellowship or are you able to learn on the job as an attending?

Thanks!

 

[cards67]

Your attendings are correct, it all becomes routine and you have to think about what you want to see, do and talk about everyday for the rest of your life. The mundane, bread and butter stuff because the excitement and thrill of things can wear off. Consider that pure EP jobs are pretty common whereas IC you're more likely to be doing gen cards as well. But with IC it might be easier to cut back to just gen cards down the road. Knowledge and ability will come with time, that's why you're in training. And I wouldn't sweat interpersonal dynamics, there are difficult characters everywhere, just gotta deal with it. I've never found EP folks to be any better or worse. Not that you necessarily have to love EP, but I feel like it should be more than "don't dislike". Is gen cards not an option?

 

[Mdinfo]

Thank you! Maybe it’s more about unfamiliarity than “dont dislike”. To be honest, I’m not entirely sure, which is why I’m reaching out to get the opinions of seniors in the field. I don’t see myself doing gen card — I prefer to sub specialize.

 

[shouldigomd]

Making career choices based on personalities you encounter in training is silly so I would remove that argument from your list of pro/con's. Personalities are obviously highly variable and also differ significantly in training vs academics vs private vs location. Don't sleep on general cardiology. It allows for the most flexibility in nearly every aspect and the job market is great. Many general cardiologist don't "sub-specialize" but ultimately practice advanced: congenital / imaging / pulm htn / heart failure and do their own diagnostic heart caths.

Not to hijack OP's thread, but I have a few questions that may be pertinent to them as well:

What does your schedule look like? Are you in PP or academic?
How did you tap into peripheral stuff/PFO/watchman etc, without a structural year? Did you aim to do as many as you could during IC fellowship or are you able to learn on the job as an attending?

Thanks!

PP. I take 1:5 IC call. Typical week is 8am to 5pm M to F. I do 1 weekend every 5 weeks. Get exposure in as much as you can during training. Don't go crazy so that you are absent from your bread and butter cardiology stuff but try and get enough of a taste of the things you could see yourself doing in the future. Vascular access and catheter techniques are pretty much the same no matter what procedures you are doing. Once you start as an attending you will see the culture and what procedures you can tap into depending on your hospital.

 

[Mdinfo]

Making career choices based on personalities you encounter in training is silly so I would remove that argument from your list of pro/con's. Personalities are obviously highly variable and also differ significantly in training vs academics vs private vs location. Don't sleep on general cardiology. It allows for the most flexibility in nearly every aspect and the job market is great. Many general cardiologist don't "sub-specialize" but ultimately practice advanced: congenital / imaging / pulm htn / heart failure and do their own diagnostic heart caths.





PP. I take 1:5 IC call. Typical week is 8am to 5pm M to F. I do 1 weekend every 5 weeks. Get exposure in as much as you can during training. Don't go crazy so that you are absent from your bread and butter cardiology stuff but try and get enough of a taste of the things you could see yourself doing in the future. Vascular access and catheter techniques are pretty much the same no matter what procedures you are doing. Once you start as an attending you will see the culture and what procedures you can tap into depending on your hospital.

Thank you very much. Appreciate your advice. Did not realize that gen cards focus their practices this way, PH ,HF etc sounds good idea.

 

[Rocher]

I was also between the two fields and was close to choosing interventional but ultimately chose EP. I am three years into my attending job and I’m super glad I chose EP.

I would disagree with the above poster with regard to pacemakers. With left bundle branch area pacing as the standard it’s definitely not a glorified central line.

I actually feel that EP has more procedural variety than interventional. I do transvenous ppm/ICDs, CRTs, leadless pacemakers, subcutaneous and extravascular ICDs, a multitude of SVT ablations, VT ablations, AF ablations, and LAAO. We deal with the entire cardiac anatomy which I like. It is definitely not boring, but I do agree that the shine does wear off. That’s when lifestyle is nice because I still have time for other hobbies. We also have a significant impact on quality of life for patients so that is also satisfying.

EP has a large knowledge base and it’s completely different from gen cards but it’s actually not difficult once you’ve gotten enough exposure (years). I wouldn’t let feeling uncomfortable with it now dissuade you if you’d otherwise be interested.

 

[Mdinfo]

Thank you. I’m interested, though not strongly—I feel I’m not naturally good at it. Still, I don’t want to look back with regret or wonder what if I had chosen differently. The two years of training are a big factor in leaning me toward IC, especially since my program is strong in this area, which also shapes how many here consider IC. I understand that one extra year is not significant when looking at a lifelong career.
Is the lifestyle what really make you go with EP? ?

 

[Rocher]

Thank you. I’m interested, though not strongly—I feel I’m not naturally good at it. Still, I don’t want to look back with regret or wonder what if I had chosen differently. The two years of training are a big factor in leaning me toward IC, especially since my program is strong in this area, which also shapes how many here consider IC. I understand that one extra year is not significant when looking at a lifelong career.
Is the lifestyle what really make you go with EP? ?

Lifestyle was a factor in my decision to pursue EP but it wasn’t the only decision. I liked arrhythmia patients and enjoyed the puzzles in morning conference and enjoyed that we were manipulating physiology in real-time in the lab. Now that I’m out in practice those puzzles don’t occur very often, most of the job is bread and butter and routine - it’s rare that I have a truly intellectually challenging case and honestly for the sake of efficiency and mental stress I prefer the straightforward cases haha.

Keep in mind EP isn’t a “lifestyle” specialty, there aren’t any after-hours emergencies but I still work 10-12 hour days.

 

[Mdinfo]

Appreciate your insight.
Is most of the after-hours work related to charting?
Just trying to understand where those extra hours per day come from since most cases seem relatively routine and there aren’t many emergencies.

 

[ewax]

Not too many emergencies but inpatient add ons can make you stay late regularly if your lab is inefficient with room turnover/prepping/transport/etc. or if you dont have dedicated anesthesia resources.

Also, procedures (both devices and ablation) can be very long so you may end up spending all morning and part of the afternoon on one case and then have several outpatient cases to follow which will also keep you later.

 

[shouldigomd]

After hours emergencies is exactly what most people define as "lifestyle" haha. That being said to re-iterate to the OP virtually any branch in cardiology can have lifestyle oriented hours vs daily grind. That is why it is important to find a job in line with your goals.

 

[BecksTriad]

I went through the same decision process during fellowship, and ultimately chose EP. I’ve now been in practice as an EP attending for several months. Like you, I knew I wanted a procedural field and couldn’t see myself spending most of my day interpreting imaging. The biggest factor for me ended up being lifestyle. I had a hard time imagining myself doing STEMI call for the rest of my career.

I matched through the 2+2 track, so I had to make my decision relatively early—around February/March of my first year. At that point, I actually didn’t know that much about EP. I was on my EP rotation, but most of my time was spent managing the consult service rather than being in the lab. I hadn’t even seen a full PVI before choosing EP, which is wild to think about now. But I knew I liked procedural work, and I felt confident that if I enjoyed cath, I would ultimately enjoy EP procedures as well.

The learning curve in EP is real, but it’s absolutely doable. The concepts are very different from everything else in cardiology, but once you’re immersed in the lab and studying regularly, things start to click. If I could make that transition, you definitely can—you just need exposure and repetition.

I joined a private practice after fellowship, and the experience has been excellent. What I appreciate most is that EP lets you truly function as a subspecialist. Outside of taking general call about once a month, my work is entirely EP. I don’t read echoes, nuclear studies, or CTs, and I’m not running a general cardiology clinic. If you do IC you will likely be expected to read graphics depending on your practice location. My day-to-day identity and workflow are centered on electrophysiology, which I really value. I often joke that being an EP is like being an ophthalmologist—no one fully understands what you do, and that’s actually a good thing because they leave you alone lol.

Overall, if you enjoy procedures, want long-term sustainability in your lifestyle, and are looking for a practice that allows you to specialize deeply rather than splitting your time across modalities, EP is a great fit.

 

[Mdinfo]

I went through the same decision process during fellowship, and ultimately chose EP. I’ve now been in practice as an EP attending for several months. Like you, I knew I wanted a procedural field and couldn’t see myself spending most of my day interpreting imaging. The biggest factor for me ended up being lifestyle. I had a hard time imagining myself doing STEMI call for the rest of my career.

I matched through the 2+2 track, so I had to make my decision relatively early—around February/March of my first year. At that point, I actually didn’t know that much about EP. I was on my EP rotation, but most of my time was spent managing the consult service rather than being in the lab. I hadn’t even seen a full PVI before choosing EP, which is wild to think about now. But I knew I liked procedural work, and I felt confident that if I enjoyed cath, I would ultimately enjoy EP procedures as well.

The learning curve in EP is real, but it’s absolutely doable. The concepts are very different from everything else in cardiology, but once you’re immersed in the lab and studying regularly, things start to click. If I could make that transition, you definitely can—you just need exposure and repetition.

I joined a private practice after fellowship, and the experience has been excellent. What I appreciate most is that EP lets you truly function as a subspecialist. Outside of taking general call about once a month, my work is entirely EP. I don’t read echoes, nuclear studies, or CTs, and I’m not running a general cardiology clinic. If you do IC you will likely be expected to read graphics depending on your practice location. My day-to-day identity and workflow are centered on electrophysiology, which I really value. I often joke that being an EP is like being an ophthalmologist—no one fully understands what you do, and that’s actually a good thing because they leave you alone lol.

Overall, if you enjoy procedures, want long-term sustainability in your lifestyle, and are looking for a practice that allows you to specialize deeply rather than splitting your time across modalities, EP is a great fit.

Thanks much for your insight. Not sure if the 2 yrs of training was an issue for your decision!

I totally agree with you — EP is like ophthalmology, a true subspecialty within a subspecialty, which I actually like. However, some colleagues mentioned a potential downside — that unlike interventional, it’s harder to “step back” later in your career and return to general cardiology. They say once you stop doing EP procedures, it’s tough to maintain a position since the field moves fast and few places keep non-procedural EPs.

 

[Cardiac Amyloidosis]

There’s no debate in my opinion. EP is way better for some of the reasons outlined. I hated procedures but if I enjoyed them I would have done EP 100%. IC is just a general cardiologist that does procedures, EP is a true sub-specialist.

 

[Dr. HWS]

There’s no debate in my opinion. EP is way better for some of the reasons outlined. I hated procedures but if I enjoyed them I would have done EP 100%. IC is just a general cardiologist that does procedures, EP is a true sub-specialist.

That’s a pretty narrow take.

IC isn’t “general cardiology that does procedures.” The cognitive load, decision-making, and acuity are completely different. Managing shock, MCS escalation, left main bifurcations, CTOs, STEMIs, iatrogenic complications, structural work, complex hemodynamics, PEs, renal dernervation therapies—none of that is just an extension of general cards. Not to mention peripheral and endovascular work which in itself could be a career focus.

EP is absolutely a deep subspecialty, no argument there. But IC has its own depth and specialization that goes far beyond “doing procedures”. Pretending one is inherently more specialized than the other is a naive take, with all due respect.

IC gives you far more flexibility in how you shape your career. You can still practice a meaningful amount of general cardiology, imaging, structural, peripheral or even shift toward more clinic-heavy roles later if you want or you could be a full time IC with different focuses (pure IC work is mainly at tertiary centers though but it's not uncommon). EP (for the most part) is more all-or-nothing; once you’re in, you’re basically doing EP full-time.

 

[shouldigomd]

Thanks much for your insight. Not sure if the 2 yrs of training was an issue for your decision!

I totally agree with you — EP is like ophthalmology, a true subspecialty within a subspecialty, which I actually like. However, some colleagues mentioned a potential downside — that unlike interventional, it’s harder to “step back” later in your career and return to general cardiology. They say once you stop doing EP procedures, it’s tough to maintain a position since the field moves fast and few places keep non-procedural EPs.

Where are you getting all this terrible info. I would stop listening to them.

 

[Cardiac Amyloidosis]

That’s a pretty narrow take.

IC isn’t “general cardiology that does procedures.” The cognitive load, decision-making, and acuity are completely different. Managing shock, MCS escalation, left main bifurcations, CTOs, STEMIs, iatrogenic complications, structural work, complex hemodynamics, PEs, renal dernervation therapies—none of that is just an extension of general cards. Not to mention peripheral and endovascular work which in itself could be a career focus.

EP is absolutely a deep subspecialty, no argument there. But IC has its own depth and specialization that goes far beyond “doing procedures”. Pretending one is inherently more specialized than the other is a naive take, with all due respect.

IC gives you far more flexibility in how you shape your career. You can still practice a meaningful amount of general cardiology, imaging, structural, peripheral or even shift toward more clinic-heavy roles later if you want or you could be a full time IC with different focuses (pure IC work is mainly at tertiary centers though but it's not uncommon). EP (for the most part) is more all-or-nothing; once you’re in, you’re basically doing EP full-time.

I didn’t mean it in a disrespectful way, maybe I could have phrased it better. What I meant is that they still care/manage many of the same things like cholesterol, HTN, etc. EP doesn’t give a crap about any of that. They just care about 3 things: EKGs, AADs, and procedures/devices. That’s it.

 

[Rocher]

Appreciate your insight.
Is most of the after-hours work related to charting?
Just trying to understand where those extra hours per day come from since most cases seem relatively routine and there aren’t many emergencies.

Cases 7:30-5:30 but can often go a bit later. Sometimes I have to see a consult I couldn’t get to earlier in the day and there’s usually some type of chart work that I have do (inbox, device reports, etc). Clinic days are easier but I like the procedure days better despite the longer hours.

 

[Dr. HWS]

I didn’t mean it in a disrespectful way, maybe I could have phrased it better. What I meant is that they still care/manage many of the same things like cholesterol, HTN, etc. EP doesn’t give a crap about any of that. They just care about 3 things: EKGs, AADs, and procedures/devices. That’s it.

I agree with that. To be a good IC, you still need to practice good general cardiology-- not the same case in EP, in which you only care about true EP aspects. That can be seen as positive or negative depending on the person's personality and overall goals.

 

[KnuckleOrDie]

IC here. I agree EP procedures are slightly more cognitive in general but complex (and particularly CTO) PCI is highly cognitive and easily on par with anything EP has to offer. EP is blessed by being able to avoid almost all general cardiology in many practices, whereas ICs will often do some general cardiology since the number of ICs in a practice is more often dictated by desire to distribute STEMI call burden than true clinical need.

IC offers the thrill of managing very acutely ill patients and truly saving a life - even after practicing for 7 years the shine has not worn off for me.

All of that being said, a reasonable adaptive person could find satisfaction in either career field.

 

[Mdinfo]

IC here. I agree EP procedures are slightly more cognitive in general but complex (and particularly CTO) PCI is highly cognitive and easily on par with anything EP has to offer. EP is blessed by being able to avoid almost all general cardiology in many practices, whereas ICs will often do some general cardiology since the number of ICs in a practice is more often dictated by desire to distribute STEMI call burden than true clinical need.

IC offers the thrill of managing very acutely ill patients and truly saving a life - even after practicing for 7 years the shine has not worn off for me.

All of that being said, a reasonable adaptive person could find satisfaction in

That’s very interesting to hear that you’re still enjoying it after 7 yrs. One of my IC colleagues, 2 yrs into practice, was sharing how stressful it is and even advised me to stay away from it, saying there’s no joy in what he’s going through.

 

[Mdinfo]

Where are you getting all this terrible info. I would stop listening to them.

So EP can step down to general cardiology if they want and still easily find positions?

 

[Dr. HWS]

That’s very interesting to hear that you’re still enjoying it after 7 yrs. One of my IC colleagues, 2 yrs into practice, was sharing how stressful it is and even advised me to stay away from it, saying there’s no joy in what he’s going through

Where I am now, most of the IC I know (even the ones that have been doing it for 15-20 years) are so passionate about it. I think making sure you have a reasonable call schedule makes a huge difference in the long terms. If you do it or anything else for the right reasons and you find a good group, you'll love it. That being said, grass is always greener on the other side.

 

[Dr. HWS]

So EP can step down to general cardiology if they want and still easily find positions?

I'm not EP, but from what I've seen (in both EP and IC) is that folks who spend all of their careers just doing pure EP or IC have a hard time going back to general cardiology. This could be for many reasons, including comfort with management of general cardiology issues, but I think an important factor is losing credentials (or not even having it to begin with) in echo, nuclear, etc (even if you have it now, if you don't read a certain number of studies over a certain period of time, you'll lost credentials). For most groups, they want their gen cards to be able to read studies (as this is a major stream of RVUs), so if you're not able to do that, you'll have a hard time finding a good position. As majority of IC people tend to still do gen cards, this may not be an issue, but it's definitely an issue for those who do pure IC. Similar for EP. That being said, if you're in a group with established presence, you may be able to negotiate something later on to do whatever you want.

From my personal experience, I know old IC folks who know just do gen cardiology after years in IC, but I don't know any EP who moved to gen cards.