Practicing Structural Interventions without STEMI call

[SunshineCoast]

Hello everyone,

Fourth year medical student here that is very interested in Cardiology. Furthermore, I would like to be involved in the procedural aspects of Cardiology, particularly the structural part. I'm a Canadian medical student but am considering coming to the US for my cardiology fellowship. I have two questions:

1. Would it be possible to work as an interventional cardiologist without taking STEMI call? For example, I know there are combined interventional and structural cardiology fellowship, and I've also seen solely interventional and solely structural fellowships. If one were to pursue just a structural fellowship, what would they employability be like and can they work at a center with a cath lab and not take STEMI call? Does anyone know of staff who practice this? The obvious reason I'm asking this is to avoid STEMI call for the rest of my life.

2. As more and more indications for transcatheter valve interventions increases (EARLY TAVR trial, TAVR UNLOAD trial) - I suspect the workload of structural cardiologists is going to increase immensely in the next decade. I'm wondering if we will ever get to a point where cardiology fellows graduate with the competency to perform these procedures without a dedicated fellowship - ie similar to GI where fellows graduate with the competency to perform scopes and various other procedures.

I apologize if my questions insinuate that I want to take the easiest path possible. I'm a medical student that is slightly on the older side compared to my classmates and I am strongly considering lifestyle and length of training when choosing my specialty.

Many thanks and I welcome any thoughts/suggestions!

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[timpview]

1. Typically not.. and definitely not as a new attending.

2. No. Training in medicine never condenses. It will remain at 8 years for the foreseeable future. Not sure if anyone is getting away with 7 anymore if doing structural too

3. Procedures + No (real) call = EP

 

[SunshineCoast]

1. Typically not.. and definitely not as a new attending.

2. No. Training in medicine never condenses. It will remain at 8 years for the foreseeable future. Not sure if anyone is getting away with 7 anymore if doing structural too

3. Procedures + No (real) call = EP

Thanks for your reply. I've read a lot of your posts on here - quick follow up - would you say the call is the worst part of IC? Does it get easier over time? Also, what do you think about the future of IC? I'm assuming there will be more job openings due to the explosion of structural interventions and hence bigger teams = less call.

Again, this is the perspective of a fourth year medical student (ie minimum 8 years of training left).
Thanks!

 

[chromaticscale]

Hello everyone,

Fourth year medical student here that is very interested in Cardiology. Furthermore, I would like to be involved in the procedural aspects of Cardiology, particularly the structural part. I'm a Canadian medical student but am considering coming to the US for my cardiology fellowship. I have two questions:

1. Would it be possible to work as an interventional cardiologist without taking STEMI call? For example, I know there are combined interventional and structural cardiology fellowship, and I've also seen solely interventional and solely structural fellowships. If one were to pursue just a structural fellowship, what would they employability be like and can they work at a center with a cath lab and not take STEMI call? Does anyone know of staff who practice this? The obvious reason I'm asking this is to avoid STEMI call for the rest of my life.

2. As more and more indications for transcatheter valve interventions increases (EARLY TAVR trial, TAVR UNLOAD trial) - I suspect the workload of structural cardiologists is going to increase immensely in the next decade. I'm wondering if we will ever get to a point where cardiology fellows graduate with the competency to perform these procedures without a dedicated fellowship - ie similar to GI where fellows graduate with the competency to perform scopes and various other procedures.

I apologize if my questions insinuate that I want to take the easiest path possible. I'm a medical student that is slightly on the older side compared to my classmates and I am strongly considering lifestyle and length of training when choosing my specialty.

Many thanks and I welcome any thoughts/suggestions!

1. No. If it is possible, then it will be very very rare to find that. One of the cons of being an interventional cardiologist is the call aspect. I'm not sure if you can do structural cardiology without having had done interventional already, but assuming you do need IC training, the employability for structural is the worst. It is like a niche and I heard that structural jobs are only at academic centers. Overall, structural cardiology has the lowest demand, then IC/EP, then noninvasive (which is white hot these days).
2. Even if the demand for structural cases increases, the techniques required for structural cardiology requires additional training. In fact, because there is so much information being revealed in cardiology (and medicine in general), there is a trend to sub-sub specialize (for instance, cardio-oncology, advanced imaging). Thus, it would actually be the opposite of what you're saying. I don't expect any general cardiology fellows to be competent in structural cardiology, nonetheless interventional which is why you need an additional year of training at least in interventional before you go out on your own in the real world.

If lifestyle is the most important to you, you will have to strongly consider if you should pursue cardiology. It requires an additional 3 years after internal medicine residency (3 years), and if you want to do interventional/structural then that is an additional 1-2 years. Moreover, even general cardiology takes call...depends on the employer but you may have to do call biweekly, 1:6 or 1:8 (1 in every 6 or 8) weekdays or weekends. Hospital medicine and primary care have better schedules than cardiology.

That being said, only do cardiology, interventional, or structural if you LOVE it and cannot imagine doing anything else. I personally cannot do interventional because of the stressful situations, taking lots of call and am not gung-ho about procedures.

 

[SunshineCoast]

1. No. If it is possible, then it will be very very rare to find that. One of the cons of being an interventional cardiologist is the call aspect. I'm not sure if you can do structural cardiology without having had done interventional already, but assuming you do need IC training, the employability for structural is the worst. It is like a niche and I heard that structural jobs are only at academic centers. Overall, structural cardiology has the lowest demand, then IC/EP, then noninvasive (which is white hot these days).
2. Even if the demand for structural cases increases, the techniques required for structural cardiology requires additional training. In fact, because there is so much information being revealed in cardiology (and medicine in general), there is a trend to sub-sub specialize (for instance, cardio-oncology, advanced imaging). Thus, it would actually be the opposite of what you're saying. I don't expect any general cardiology fellows to be competent in structural cardiology, nonetheless interventional which is why you need an additional year of training at least in interventional before you go out on your own in the real world.

If lifestyle is the most important to you, you will have to strongly consider if you should pursue cardiology. It requires an additional 3 years after internal medicine residency (3 years), and if you want to do interventional/structural then that is an additional 1-2 years. Moreover, even general cardiology takes call...depends on the employer but you may have to do call biweekly, 1:6 or 1:8 (1 in every 6 or 8) weekdays or weekends. Hospital medicine and primary care have better schedules than cardiology.

That being said, only do cardiology, interventional, or structural if you LOVE it and cannot imagine doing anything else. I personally cannot do interventional because of the stressful situations, taking lots of call and am not gung-ho about procedures.

I appreciate the insight. Would you mind also clarifying a little about some of the procedures general/non-invasive cardiologists are doing in the US? I've read on forums that general cards in the US is reading echos/nuc studies, performing TEEs, performing caths, is this actually true with just the 3 years of cardiology training? Including the major cities?

Here in Canada general cardiology isn't really doing any of these anymore and it's quite a bummer as I would like to get involved with some procedures but perhaps IC isn't for me with the STEMI call and I'm not sure if EP is right for me.

 

[deleted980918]

Structural jobs without STEMI call do exist but that’s often seen in established providers. As IC, one of your best asset to a hospital is STEMI coverage. If you don’t want to do STEMIs, you better be damn good at structural procedures and bringing in a lot of pts from that revenue stream, both of which are rarely seen in new grads.

 

[timpview]

Thanks for your reply. I've read a lot of your posts on here - quick follow up - would you say the call is the worst part of IC? Does it get easier over time? Also, what do you think about the future of IC? I'm assuming there will be more job openings due to the explosion of structural interventions and hence bigger teams = less call.

Again, this is the perspective of a fourth year medical student (ie minimum 8 years of training left).
Thanks!

1. Yes. IC call is horrific to me. Gen call is completely dependent on group practice (can be very easy to bad). IC call to me is always bad.

2. Call has gotten significantly worse to me over time. It just gets really old. I've debated many times quitting IC and just doing General solely because of it. Some (esp the older generation) seem to tolerate/not mind it as bad so who knows. Maybe you can deal with it better. But night work changes personalities, relationships, is a CV risk factor and will take time off the back end of your life. So it makes no sense to me to purposely choose such a career path with what I know now.

3. The future of IC will be interesting. Our main value is and will be STEMI call. So I don't ever envision a time when we're not a top 5 paid specialty and the job market I feel will only be open for such reasons. I also don't think the younger generations will endure/put up with what the older generations did (and still do) when it comes to work load, call, ect, nor will they allowed by hospitals to be the "busy" interventionalists from back in the day, so I don't think supply will match demand. I do think we'll see a shift in consolidation (rather than an expansion) of STEMI programs/hospitals because they just won't be able to staff them (I'm already seeing this). But I do think they'll do everything possible not to have that be the case and you'll always have value. Also, even if the hospital employed structure changes, Cardiology will always be positioned as strong as anyone given our multiple revenue pathways and the fact that patients and referring docs are freaked out by cardiac symptoms.

The issue will be how will the structuralists fit into that. Structural cases aren't really "exploding" and there's probably somewhat of a cap on them in most markets even if things do continue to expand (mitral work, etc). Because of that I think there is and there will be a gluttony of structurally trained IC going forward.

The thing is everyone coming through the ranks now will likely want to do structural. It's not that you're a bum if you don't, but most idealistic/enthusiastic new grads aren't going to want to do 15 years of school/training to not be considered on par with someone else in their career pathway... and I think that skill set gap will only widen. The majority of conferences going forward will be focused on structural cases. I bet all the innovation, all the industry relationships, etc will also be focused on that as well (at least for the near future). Coronary innovation has been tapped out imo and with coronary volume stagnant or decreasing and study after study questioning non-acute coronary work, I just don't see that changing any time soon. That's not to say that coronary work won't still be what is most valued, but its just nearly as sexy as everything else and new trainees will recognize that. So I think you'll see a distinction of groups and that current fellows have one of 4 groups to choose from...
1. General + Imaging
2. General + Heart failure
3. What I call General + Coronary (IC coronary only guys that spend majority of their practice doing general cardiology)
4 Skilled Interventionalists (structural plus coronary +/- peripherals or those with a lot more procedure days/time and a lot less clinic responsibilities, call). I think this group will be the most desired of new grads but won't have the jobs to support such demand as it only takes a couple to lock down a market.

4. General cardiologists don't do "procedures" imo. They do "things that break up the monotony of clinic". Them dinking around w/ caths just wastes everyone's time and eventually that will go away. Less and less do pacers and that will go away. TEEs are lame. The exception being the guys that really focus on imaging and/or do the TEEs for the structural cases, but even with that not sure how anyone finds that exciting though they do bring value.

With that said. The current RVU format benefits General guys. Outpatient RVU codes have increased. Busy clinic + inpatient consults + possibly cath/TEE/DCCVs + holters/pacer interrogations and especially plus imaging means you can generate a ton of RVUs without the risk and mental/physical grind of a 3 hour CTO case. So there is value (as of now) and the pay can be equivalent (or even higher) than many IC guys because the churn and burn coronary mills are a lot less less prevalent now. I do think you'll see more and more either choose imaging or heart failure as their focus and I do think they'll always maintain value even if they're slightly more at risk of the midlevel invasion.

 

[SunshineCoast]

1. Yes. IC call is horrific to me. Gen call is completely dependent on group practice (can be very easy to bad). IC call to me is always bad.

2. Call has gotten significantly worse to me over time. It just gets really old. I've debated many times quitting IC and just doing General solely because of it. Some (esp the older generation) seem to tolerate/not mind it as bad so who knows. Maybe you can deal with it better. But night work changes personalities, relationships, is a CV risk factor and will take time off the back end of your life. So it makes no sense to me to purposely choose such a career path with what I know now.

3. The future of IC will be interesting. Our main value is and will be STEMI call. So I don't ever envision a time when we're not a top 5 paid specialty and the job market I feel will only be open for such reasons. I also don't think the younger generations will endure/put up with what the older generations did (and still do) when it comes to work load, call, ect, nor will they allowed by hospitals to be the "busy" interventionalists from back in the day, so I don't think supply will match demand. I do think we'll see a shift in consolidation (rather than an expansion) of STEMI programs/hospitals because they just won't be able to staff them (I'm already seeing this). But I do think they'll do everything possible not to have that be the case and you'll always have value. Also, even if the hospital employed structure changes, Cardiology will always be positioned as strong as anyone given our multiple revenue pathways and the fact that patients and referring docs are freaked out by cardiac symptoms.

The issue will be how will the structuralists fit into that. Structural cases aren't really "exploding" and there's probably somewhat of a cap on them in most markets even if things do continue to expand (mitral work, etc). Because of that I think there is and there will be a gluttony of structurally trained IC going forward.

The thing is everyone coming through the ranks now will likely want to do structural. It's not that you're a bum if you don't, but most idealistic/enthusiastic new grads aren't going to want to do 15 years of school/training to not be considered on par with someone else in their career pathway... and I think that skill set gap will only widen. The majority of conferences going forward will be focused on structural cases. I bet all the innovation, all the industry relationships, etc will also be focused on that as well (at least for the near future). Coronary innovation has been tapped out imo and with coronary volume stagnant or decreasing and study after study questioning non-acute coronary work, I just don't see that changing any time soon. That's not to say that coronary work won't still be what is most valued, but its just nearly as sexy as everything else and new trainees will recognize that. So I think you'll see a distinction of groups and that current fellows have one of 4 groups to choose from...
1. General + Imaging
2. General + Heart failure
3. What I call General + Coronary (IC coronary only guys that spend majority of their practice doing general cardiology)
4 Skilled Interventionalists (structural plus coronary +/- peripherals or those with a lot more procedure days/time and a lot less clinic responsibilities, call). I think this group will be the most desired of new grads but won't have the jobs to support such demand as it only takes a couple to lock down a market.

4. General cardiologists don't do "procedures" imo. They do "things that break up the monotony of clinic". Them dinking around w/ caths just wastes everyone's time and eventually that will go away. Less and less do pacers and that will go away. TEEs are lame. The exception being the guys that really focus on imaging and/or do the TEEs for the structural cases, but even with that not sure how anyone finds that exciting though they do bring value.

With that said. The current RVU format benefits General guys. Outpatient RVU codes have increased. Busy clinic + inpatient consults + possibly cath/TEE/DCCVs + holters/pacer interrogations and especially plus imaging means you can generate a ton of RVUs without the risk and mental/physical grind of a 3 hour CTO case. So there is value (as of now) and the pay can be equivalent (or even higher) than many IC guys because the churn and burn coronary mills are a lot less less prevalent now. I do think you'll see more and more either choose imaging or heart failure as their focus and I do think they'll always maintain value even if they're slightly more at risk of the midlevel invasion.

Really good insight here, appreciate the reply.
Would you mind clarifying what your call schedule is like? On average how many times are you getting called in per shift? Are you in a major city? I'm wondering if IC groups in major cities have better call shifts? I think one of the major pros of IC is that you can always fall back on gen cards, but I suspect the transition to gen cards might be boring for people who enjoy the procedural work, and I'm only assuming you are one of them, let alone the opportunity cost of the extra training, etc.

Personally for me I think this just highlights the importance of really thinking through your career decision.. I like IM but I'm not sure if I like the other procedural specialties - i.e GI/pulm/ICU. Makes me question whether I should just go through primary care and actually focus on other specialties like sports medicine / pain / cosmetics on the side to get that "procedural fix" without I guess going through not only a brutal IM/cards/IC training but also have a difficult staff life. I'm beginning to think my personality fits more in line with surgery but it's too late to switch as I've completed most of my fourth year electives already.

Any other advice would be appreciated. Thanks everyone.

 

[timpview]

Yea tough call. The nice thing with IM (and with cards) is that you do keep your options open for a lot of different pathways. Obviously there are still some different things you can do with family medicine and others, but IM has more pathways out of med school than anything else. It's not even like you have to decide about IC vs. Gen cards for 4-5 years too.

I get called in 50-75% of the time on a q5 basis. To me that's the worst because pager anxiety is real when you're pretty sure you're going to get called in at some point during the night (and when you know you're working the next day). I think the really busy call places might be better as you are seeing some of those go to more shift work with post call day schedules. If I happen to have the next day off my anxiety drops a ton because I know if the night is awful I can recover the next day. But as I'm getting older a bad Monday night basically ruins my week now. More frequent (q2-3) is also awful when you're tied to the pager that often, though usually the high frequency places have lower volumes (3-4 STEMIs a month).

Also a lot of call is dependent on local/job factors so obviously its not so much of how often you're coming in for a STEMI but how many phone calls and responsibilities do you have- how many ER phone calls, how many referring hospitals staffed by PAs are there, how many inpt consults, how many nursing calls, are you primary on patients, do you have people admitting for you or are you responsible for admitting MIs to AF, HF, etc, are your STEMIs mostly through your ER or being transferred from 2-4 hours away (which really suck at 11 pm), do you have somewhere to send your Impella patients or are you answering every page for them all weekend, are you an outpt care coordinator at 2 am needing to schedule ER follow ups, are you answering direct patient calls throughout the night. So much of that is dependent on group size, local culture, admin support, hospitalist support, but you can see that you potentially could get hit from a 1000x different places. Now, some groups have really strived to knock off at least some of that non-emergent nonsense, but the majority of places in my area really haven't figured it out.

For me in the specialties that are the worst are those that have heavy call + work the next day... The default archaic Cardiology schedule is based on "time off" per month (which usually doesn't work in our favor) rather than "number of shifts you work each month." It's a key distinction. You start adding up your regular work days and your call than your "shifts per month" can start looking pretty ugly esp when compared to the shift-based specialties (critical care, ER, etc).

 

[chromaticscale]

I appreciate the insight. Would you mind also clarifying a little about some of the procedures general/non-invasive cardiologists are doing in the US? I've read on forums that general cards in the US is reading echos/nuc studies, performing TEEs, performing caths, is this actually true with just the 3 years of cardiology training? Including the major cities?

Here in Canada general cardiology isn't really doing any of these anymore and it's quite a bummer as I would like to get involved with some procedures but perhaps IC isn't for me with the STEMI call and I'm not sure if EP is right for me.

General/non-invasive cardiologists do some procedures, mainly TEEs. Other than seeing patients in the clinic or hospital, they will read echos and nuclear studies, supervise stress tests (exercise ECG, stress echo) and interpret them, and provide the final interpretation of ECGs (usually it is "not confirmed" electronically until later when an attending reads it) and Holter monitors. They may also interpret CT/MRI if they are certified to do so.

Invasive cardiologists have the additional responsibility of performing diagnostic caths but do not place stents or perform PCI, unlike interventional cardiologists who have at least an additional year of training. Both noninvasive and invasive cardiologists are able to practice as attendings after 3 years of general cardiology fellowship. Does not matter if it is a major city or rural area (though demand and salary will be higher in the latter).

 

[SunshineCoast]

Yea tough call. The nice thing with IM (and with cards) is that you do keep your options open for a lot of different pathways. Obviously there are still some different things you can do with family medicine and others, but IM has more pathways out of med school than anything else. It's not even like you have to decide about IC vs. Gen cards for 4-5 years too.

I get called in 50-75% of the time on a q5 basis. To me that's the worst because pager anxiety is real when you're pretty sure you're going to get called in at some point during the night (and when you know you're working the next day). I think the really busy call places might be better as you are seeing some of those go to more shift work with post call day schedules. If I happen to have the next day off my anxiety drops a ton because I know if the night is awful I can recover the next day. But as I'm getting older a bad Monday night basically ruins my week now. More frequent (q2-3) is also awful when you're tied to the pager that often, though usually the high frequency places have lower volumes (3-4 STEMIs a month).

Also a lot of call is dependent on local/job factors so obviously its not so much of how often you're coming in for a STEMI but how many phone calls and responsibilities do you have- how many ER phone calls, how many referring hospitals staffed by PAs are there, how many inpt consults, how many nursing calls, are you primary on patients, do you have people admitting for you or are you responsible for admitting MIs to AF, HF, etc, are your STEMIs mostly through your ER or being transferred from 2-4 hours away (which really suck at 11 pm), do you have somewhere to send your Impella patients or are you answering every page for them all weekend, are you an outpt care coordinator at 2 am needing to schedule ER follow ups, are you answering direct patient calls throughout the night. So much of that is dependent on group size, local culture, admin support, hospitalist support, but you can see that you potentially could get hit from a 1000x different places. Now, some groups have really strived to knock off at least some of that non-emergent nonsense, but the majority of places in my area really haven't figured it out.

For me in the specialties that are the worst are those that have heavy call + work the next day... The default archaic Cardiology schedule is based on "time off" per month (which usually doesn't work in our favor) rather than "number of shifts you work each month." It's a key distinction. You start adding up your regular work days and your call than your "shifts per month" can start looking pretty ugly esp when compared to the shift-based specialties (critical care, ER, etc).

Thank you for clarifying all of this. I wish you all the best... you're doing godsend work and I hope you can find the right balance for you soon. Much love!