So You Want to Be a Cardiologist

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So you want to be a cardiologist. You’ve come to the right place! In this third post of So You Want to Be, let’s talk about what it means to be a cardiologist, how to become one, and some of the hidden perks and downsides of being a heart doctor.

 

What is Cardiology?

The heart is comprised of 4 chambers: two atria, and two ventricles. The right side of the heart pumps blood to the lungs to oxygenate it, so that the left side of the heart can pump the oxygenated blood to the rest of the body.

Cardiology is the specialty of medicine dealing with the heart and some specialized circulatory pathologies. If you like medicine and find physics and fluid dynamics interesting, cardiology may just be for you. It was personally one of my favorite blocks we studied in medical school.

Cardiologists are also one of the few doctors that can actually save a life during an in-flight emergency. Obviously cardiologists are the go-to doctors for heart attacks –  the technical term for which is “myocardial infarction” – but they also handle many other pathologies such as high blood pressure (known as hypertension), high cholesterol (known as hyperlipidemia), and irregular heart rhythms (known as arrhythmias).

It’s not a surgical specialty, but it’s also not a traditional medical specialty. Cardiology is unique in that it’s more procedural than the average medicine specialty. Cardiologists have several cool non-invasive tests like electrocardiograms, or ECGs, and echocardiograms or cardiac CTs and MRI’s. But invasive tests are also part of the job such as coronary angiography, catheterization, or electrophysiology studies.

 

How to Become a Cardiologist

To become a cardiologist, you don’t go to cardiology residency. There’s actually no such thing. First, you complete 3 years of internal medicine residency. This is actually the number one most common residency that medical school graduates pursue. Think of it as the default.

However, after internal medicine residency, you can choose to sub-specialize, and that’s where fellowship comes in. Cardiology is one of the most competitive internal medicine fellowships and requires another 3 years of training to complete. In total, you’ll be spending 6 years in addition to medical school to become a cardiologist. If you want to sub-specialize further, such as interventional cardiology, or electrophysiology, tack on another 1 or 2 years on top.

If you want to do pediatric cardiology, that’s a slightly different process. Rather than internal medicine residency, you’ll do three years of pediatrics, and then three years of pediatric cardiology fellowship.

Becoming a cardiothoracic surgeon is an entirely different process. At its core, CT surgery is a surgical specialty, and therefore it makes sense that you have to do a surgical residency rather than a medicine residency. There are two main paths. First, you can do 5 years of general surgery residency, plus 2-3 years of cardiothoracic surgery fellowship. Or second, do a 6 year integrated cardiothoracic surgery residency.

 

What’s It Like Being a Cardiologist?

Cardiology is a “best of both worlds” specialty. A fantastic, tunable combination of acute and chronic medicine, satisfying those who like fast-paced critical illness while still allowing the long term relationships with patients and disease that make medicine so rewarding. It also combines the best of medicine and surgery; multi-system disease processes and diagnostic challenges alongside increasingly complex and essentially surgical interventional procedures.

 

Cardiology can be divided into a few broad areas:

  • Intervention – involves invasive procedures such as coronary angioplasty and valve implantation. “The orthopaedic surgeons of medicine” which is a little unfair (but only a little)
  • Heart failure – ranging from managing an outpatient or community-based service for patients with impaired hearts to running a cardiac ICU specializing in mechanical support and transplants. The specialist generalists.
  • Electrophysiology – the management of rhythm disorders with medications and invasive ablation procedures. The ECG nerds.
  • Devices – the management of heart rhythm disorders with medications and by implanting pacemakers and defibrillators. Also ECG nerds.
  • Imaging – cardiologists who are experts at the non-invasive scanning techniques. Often combined with heart failure. The glue that sticks cardiology together.
  • Other fields – adult congenital heart disease, sports cardiology, preventive cardiology, women’s and obstetric cardiology.

 

Choice of specialty hugely affects a typical working day, but with ever-increasing levels of heart disease and an aging population, all cardiologists are busy. A typical week for an interventional cardiologist might include a couple of days in the cardiac cath lab, performing a combination of emergency and elective procedures, a half-day clinic, half-day reporting or performing echocardiograms and cardiac MRI scans, daily coronary care unit, general ward rounds and some time set aside for research. Cardiology is a very academic field with many physician-clinicians, but it is not mandatory. However, it is the most evidence-based specialty there is, so a thorough understanding of research is essential.

On calls are invariably busy – 30-40% of emergency room admissions are cardiac- related, whether from chest pain, loss of consciousness or breathlessness. Intervention is not a subspecialty to choose if you don’t wish to have to come in most nights on call.

Though it’s commonly thought that cardiology is not conducive to having a normal personal and social life, there are still many cardiologists who enjoy their free time. There is also an increasing recognition we need to improve working lives if we want to attract a diverse workforce. That said, cardiology is certainly a specialty that attracts the top performers, and as such, is consistently one of the most competitive specialties to enter.

 

Pay/Compensation

Cardiologists are paid well in comparison to other doctors, in pretty much all countries. In the UK and USA, they are consistently in the top 3 earning specialties overall. Those that can bill for scans or procedures enjoy the largest paychecks; and there are ample opportunities for involvement with the pharmaceutical or lucrative device industries, if that is an option you’re interested in. We have covered the specifics of cardiologists’ pay in a separate post.

 

The Best Aspects of Cardiology

  • Results are immediate, and often, treatments are fairly straight-forward: heart has stopped, restart it; artery is blocked, unblock it. If a patient is in tamponade and grey, you drain the fluid, the patient’s blood pressure returns and they’re pink. On the other hand, if you enjoy the slow application of time and tinkering, that’s available too!
  • It’s largely concept-based. Cardiology centers largely around logical physiology, with great emphasis on understanding concepts rather than learning lists of microbes or molecules.
  • One can combine critical care and long-term care. One day, you may be managing patients in cardiogenic shock. The next, you could be working to improve the heart health with a 100-year-old patient whom you’ve been seeing for years; or you could help a 21-year-old with dilated cardiomyopathy become a mom. Cardiology is endlessly adaptable.
  • Treatment options are phenomenal. Not so long ago, patients with large heart attacks were tucked into bed with a cup of tea. The adoption of thrombolysis helped, but it also caused a host of new problems. Then finally, the advent of PPCI sent death rates from STEMI plummeting, saving millions of lives. Now, we also have access to heart transplants and artificial hearts. We have pacemakers the size of jelly beans! And importantly, there have been few leaps forward in medicine as dramatic as primary percutaneous angioplasty. One of the most exciting treatments in cardiology, currently, is transcatheter aortic valve implantation (TAVI, or TAVR). Recent evidence suggests that TAVI will overthrow the surgical aortic valve replacement for the majority of patients, in the same way that coronary stenting decimated coronary artery bypass numbers. In just a few years, it’s likely that we will come to regard opening up someone’s chest to replace their valve as a barbaric relic of the past.

Lastly, cardiology tends to be a great choice for doctors who find themselves on the fence between medicine and surgery.

 

Downsides to Cardiology

As numerous as the glories of cardiology are, every specialty has its downsides. The workload in cardiology can be intense, and this has created a perception that cardiology will consume your life. This perception certainly isn’t always the case, but there is a reason it exists.  Because the workload is so intense, cardiology is generally not regarded as family-friendly. It’s also a specialty with one of the lowest ratios of women to men. These patterns and perceptions are slowly changing, but there’s still a long way to go.

Cardiology attracts hyper-competitive people, so one should be mindful of how you will interact with his/her colleagues. Cardiologists sometimes have a reputation for ruthless pimping and intimidating behavior. This trend is also changing – and we need nice, even-tempered people to join our ranks!

In these days of super-specialization, the general cardiologist is becoming a thing of the past as people focus on smaller areas of interest – a trend reflected across medicine. If you’re interested in a very particular aspect of the heart or a certain disease, you might really love the hyper-specialization. But if you’re interested in spanning many different areas, this trend could be a little difficult to fight against.

 

How to Tell If Cardiology is Right for You

A budding cardiologist is likely to enjoy caring for complicated, sick patients and be willing to work hard. You probably were more fond of math and physics than you were of chemistry. Physiology was your favorite pre-clinical science. You like action and are decisive. I personally don’t think intelligence correlates to making a great cardiologist, but simply due to the high bar for entry into the specialty, you are likely to have excelled academically.If you’re considering other acute medical specialties like intensive care, respiratory or gastro, remember cardiology involves almost no exposure to disgusting bodily fluids.

If these traits apply to you, cardiology is likely a good fit! But keep a few things in mind:

(1) Since so many more people are surviving heart attacks now, there is falling mortality but rising morbidity and the real growth areas within cardiology are heart failure and imaging.

(2) If you want to avoid the high rates of burnout in cardiology – not too far behind emergency medicine – you need to maintain a healthy work-life balance.

(3) Remember to think ahead. When you’re in your 20s with no kids, an onerous on-call schedule and sleep deprivation may seem like a walk in the park; but try to think ahead about what area you want to spend thirty or more years of your life. You might be less enthusiastic about a 4am angioplasty when you’re 50.

If you’re considering going into cardiology, chat with as many cardiologists as you can, spend some time shadowing them and start giving your resumé an acute medical flavor early on by getting involved with audits and research within the specialty.

 

Which specialty should we cover next in our So You Want to Be series? Let me know with a comment down below.

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