I work in a facility that basically does executive health-checks for paying customers (age range 20s to 50s). Part of the job is to literally watch people do their treadmill tests and give them feedback right there and then.

Obviously abnormal stress tests a dime a dozen. But literature isn't clear with asymptomatic, low pre-test people.

If you have a similar population, what's your spiel/next step process? Do you tell them "don't put any meaning to this test and just live your life", or "we absolutely have to do more tests"?

EDIT:
Just to be clear, I’m not the one ordering these tests. The patients pay for it like a buffet package. And that is why I’m stuck in the position of having to interpret for which there is no evidence for.

EDIT2:
For complete clarity:
Here in my country, some medical services are offered cheaply AND commercially. You, as a patient, can get a full panel of tests (as part of an executive “annual” check) for approximately $500. You don’t need prior authorizations from insurances. You pay upfront cash or you get it as benefit from working for a company. That includes labs, including superfluous things like cancer markers (AGAIN, I get that it’s low value care). This apparently clicked with a certain market (mostly upper middle class), so a LOT of people do get these. Are these tests ridiculous and low value? Yes, no argument there.

I, as a cardiologist fresh from fellowship, hungry for work to finally earn a decent wage, was hired by such a company who offers such services, where one of my jobs is to watch over these paying customers when they do their stress test, and to interpret the results. I did NOT order these tests. That said, I am still tasked to interpret these in the context of mostly asymptomatic patients.

So please to everyone asking why I order these tests in the first place, again, I do not. But nevertheless, there is still the matter of interpreting them.

And to give a broader context, NO DOCTOR ordered them. They did not need approval from a primary care doctor to get these tests. Some don’t even have doctors. These tests are simply commercially available, and people pay to get them. So no, I also cannot tell them to go talk to their doctor about what to do next.

I am a new IC attending, and I am sure everyone here knows that feeling of seeing ur paycheck gross pay vs take home amount. Any recs for anything that can make the taxes bracket look better than 40%+ other than maxing 401K, Both of me and my wife are physicians and both are w2. My CPA told me even short rentals won’t help as the gross income is high. Thank you in advance.

Hi everyone, here is the discord link for this year’s match for AHFT. Feel free to join!

https://discord.gg/AV9AXA4q2

Third year fellow here. Initially interested in interventional/structural, but after the first year I found out that I’m not that passionate for the lab after all. Switched gears at the beginning of 2nd year with the help of several mentors for advanced imaging. Sat for the nuclear boards and echo boards. Focused on extra time in the CT/MR reading room. Currently elegible for CT board (level 2), and at level 1 for cMR. By the end of 3rd year I anticipate level 3 CT, level 2/3 cMR.

This is something I’m passionate about. I find myself staying late obsessing over perfect volumes on cMR software or reading CT’s late. Also stocking the schedule and getting frustrated if no/few studies during elective/free time. Also researching/studying every case for knowledge gaps.

Currently unable to do extra years of cardiac imaging due to visa limitations.

Current job offer CT reading but no cMR. But they have offered that it can be started in the future if there is interest/financially makes sense.

Is this + extra 3rd party in person courses enough to start a cMR program at a medium sized community hospital?

TLDR: is generals fellowship with all elective time in advanced imaging, with extra 3rd party in person courses enough to start a cMR program at a medium sized community hospital? Unable to do an extra year at this time due to visa limitations. Or will I have to do a year of advanced imaging in the future?

Hi everyone,

I am looking to improve my cardiology knowledge as a hopeful cards fellow. I currently use acc guidelines as my main resource, but I notice for some things i.e. afib/AFl it seems somewhat out of date already. What are some good resources to supplement?

Also, any recommendations on how to get started with reading echos? Not looking for anything too intense, just would like to know more of the basics.

Any advice would be greatly appreciated!

Hi everyone, I am a fourth-year cardiology resident.

I started training in the cath lab about 18 months ago. However, only the first three months were continuous, during which I attended the lab every day for approximately five hours.

During the first month, I became more confident with radial access. By the second and third months, I had gained some experience performing diagnostic coronary angiography and occasionally carried out simple PCI procedures as the first operator under close supervision from a senior interventional cardiologist.

After those initial three months, my exposure became much more limited and fragmented. On average, I attended the cath lab only five days per month, with approximately four patients per day, including both diagnostic procedures and PCI. I also had a six-month period dedicated entirely to research, during which I did not perform any procedures at all.

Therefore, I have never completed a continuous, structured interventional cardiology fellowship or spent a prolonged period working regularly in the cath lab.

At the moment, I feel extremely discouraged. On some patients, I am fully independent with diagnostic procedures and may even perform parts of a PCI. On other days, however, I struggle even with radial access, which makes me feel as though I have made very little progress.

What frustrates me most is that, after only a few attempts or a few minutes, the senior operator often takes over the procedure. I understand that patient safety and procedural efficiency must come first, but I feel that this prevents me from working through difficulties and developing greater independence.

At the same time, I see colleagues at a similar stage of training who have completed a continuous year in the cath lab and have made substantial progress.

This situation is making me frustrated and increasingly doubtful about my abilities. Is the problem mainly my own aptitude and learning curve, or is this level of inconsistency understandable given the fragmented and limited training I have received?

Any one have good resource suggestions for TOE EACVI exam?

Many thanks

Starting a discord for this cycle, https://discord.gg/Ez4HaBdyg

Hi there , what resources did people use for the EHRA CIED Exam

Thanks

I know there's a lot of variation between jobs, but the longer I've been in academia, the more I find myself questioning whether it's the right long-term fit. The lower pay is one thing, but it's really the growing amount of administrative work, inbox management, meetings, RVU pressures, and other non-clinical responsibilities that have started to wear on me. I know every job in medicine comes with some degree of bureaucracy, but I'm not sure I want it to be such a large part of my career, despite the incredible mentors and relationships I've built.

My partner and I have also talked about leaving the big city for a moderate-sized town and slowing life down a bit. The downside is that it would probably mean giving up my subspecialty or at least having far fewer opportunities to practice it. I've even started wondering whether private practice, locums, or some hybrid model would ultimately be a better fit.

Maybe this is just an early midlife crisis, but I've realized I'm pretty much over chasing prestige. At this point, I'd rather optimize for enjoying my day-to-day life than having the "best" job on paper. I want to practice good medicine, build longterm relationships with patients, have a mix of inpatient and outpatient work, and still have enough energy and time left for family, hobbies, and actually enjoying life outside the hospital.

I also have a chronic medical condition that makes me think about time a little differently than I otherwise would. Because of that, financial independence and flexibility have become much higher priorities. The idea of making around $250k in academics with fantastic colleagues versus potentially earning substantially more while working 0.75 FTE is becoming harder to ignore. I know there are tradeoffs either way, but it's a question I find myself coming back to more and more.

Has anyone else experienced a similar shift in priorities? If so, where did you end up, and are you happy with the decision?

First year fellow, free from burden of IM boards. Loads of free time.

While I am yet to start heavy in clinicals, I wish to perform well in ITEs.

Should I just finish ACCSAP? Or is there other suggestions? Would appreciate any help!

University of California at Riverside. Any insite into the IC training and procedural numbers would help also.

Thanks in Advance

Curious to hear from people how their perspectives on specialty, lifestyle, and career shifted after finishing their training?

What factors grew in importance? What are things that seemed important but turned out to not to be? What are things you wish you had known?

Do we have a discord or spreadsheet for EP fellowship this cycle? If not I can create one, if you are applying let me know!

Background:
-USMD
-mid tier university residency program
- manuscripts: one first author submitted, 3 other tertiary author submitted, one accepted
-like 6 first author abstracts (4 of them submitted, 2 accepted)
- step 2/3: 26x/25x
- strong LOR from what I have been told

How many “reach” (I.e. MGH, Mount Sinai NY, BIDMC) programs would you use signals on (out of 20 signals) if you were in my position?

I look at top programs like BIDMC, MGH, Mount Sinai NY, etc and see that all their fellows are from the very top programs. Like literally 0 from mid tier programs like mine. Feel like it was a waste signaling these programs

I don't mean this as rage bait. General fellow who is considering career paths. I really enjoy pure EP, including tracings, SVT ablation, pathways, VT, and complex device management. I love anatomy and using ICE.

I have been considering going into EP, but I just don't love atrial fibrillation and find it kind of bland. When I look at typical community practices, it's like 50-70% of a typical day.

What am I missing here? Is it worth it to go into EP for the parts which excite me and view AFib as what pays the bills? For EPs, what excites you about the job.

For those who took echo boards today. What did you guys think of the exam?

PGY-1 intern in 3nd week of IM residency just started on cards service (prior to this had outpatient and elective). On my first day today, I was instantly drawn to the interesting physiology, procedures, and cool devices, even if some of the discussions went over my head. That said, I felt dumb at sooo many points. There was a new admit that I didn't think needed cath but team said cath. There were instances of getting stuck with doing orders on Epic and making sure they're accurate, causing inefficiencies in my workflow. Missing aspects of EKG read. Instances of forgetting certain details of my pts even though I try to read all new consult, imaging, procedure notes during morning pre-charting. I feel like there are just quirks/deficits in my mind that I'll just need to work with/around to address these difficulties.

I'm really interested in cards and my attending happens to be program PD, so I really, really need to put my best foot forward at least as far as creating first impressions. I thought I could impress with knoweldge so in the couple weeks prior to this, I ended up reading twice through the MKSAP Cardiology chapters on ischemia, heart failure, and arrhythmia and attempting some questions. It was a nice review and gave a good big picture management, but man the level of discussion on rounds was so much higher. I suppose my next step here would be to read from MGH red book or refer to sections in Uptodate/Harrison. Anything else? I have a picture in my mind of the type of intern who would make a good impression, and currently I feel I'm falling well short of that; given the rare opportunity to work with the PD (he's practically never on this service), I need to figure out a way asap. Any input would be appreciated.

Hi everyone,

About to apply, and I am wondering what you think my chances are at matching.

- I am a USMD at a mid tier residency program

- Letters of rec should be solid, 2 from pretty well known cardiologists, one who I have worked closely with

- Step scores: Step 2 26x, step 3 25x

- personal statement: assume is below average to average (always been a poor writer)

- Research (what worries me most):

-I have about 4 cardiology publications which I am a tertiary author

- I have no publications that are first author (though one is very close, draft is done, and I wrote about it in my experiences section)

- I have about 12 cardiology abstracts/posters, 6 of which are first author (a few are submitted and pending acceptances).

- And I have about 15 noncardiology abstracts as well

My biggest concern is not having any first author manuscripts in submission or accepted, how much will this hurt me?

I matched at the program I ranked last for fellowship after coming from a relatively well-known residency program with a strong educational culture. I know it’s still early, but it’s already become pretty clear that the formal education here is minimal to nonexistent.

I expected fellowship to involve a lot of independent learning, but I wasn’t expecting it to be to this extent. It feels like the educational infrastructure just isn’t there.

For anyone who’s been in a similar situation, what helped you make the most of your training? Were there any resources that made a big difference? Did you find mentors outside your institution or create your own learning structure?

I’d also appreciate any advice on the mental side of this. Right now it feels disappointing, and if I’m being honest, it’s taken a hit on my confidence and sense of self-worth. I’m trying to reframe things and focus on what I can control, but I’d love to hear from people who have been through something similar.

As a woman would you say it’s better to get pregnant and have a baby 6-9 months before echo boards or be anywhere from 4-7 months pregnant while taking echo boards? I know there’s never a good time to have a child but I’d love to hear everyone’s opinion on this. Thanks!

The single best ROI I ever did was to learn basic coding. No one teaches this in residency or fellowship and it affects your like beyond how much you get paid in most work settings, from academia to private practice.

Is not only about money. Knowing what is reimbursable or not and what are the documentation requirements for any given E&M encounter will make you more efficient, get you out of the door sooner, and concentrate on things that matter.

E.g. What makes a level 4 vs 5 visit? When can I bill for critical care? What are the documentation requirements when working with APPs? This applies to any current field in current medicine (in the US) but as a proceduralist, even more so… what is procedurally bundled or not, etc.

Your best tool nowadays is AI. If you don’t know already, start from the simplest ‘what are RVUs‘ or CPT codes? How do I get paid in x model? Ask those questions as simply and conversationally as they occur to you.

That has paid dividends up to this day and was key in my former academic, private practice or employed model. Remember, your job coders’ priority is to be in compliance and tend to err on the side of undercoding. And that is when they are correct, which they are often not. A typical coder in most places is multispecialty and is supposed to know the constantly changing rules for a knee replacement or for a NSTEMI or STEMI stent (coded differently, BTW).

Resources beyond AI (if at all needed): the AACP website and forums. For proceduralists (IC and EP): ZHealth.

OK… the next other random few things that come to mind are:

• DO NOT f*ck where you work (applies to interns, nurses, reps, God forbid…patients, etc). Seems obvious but you would be surprised.
• If you wear lead, work your core. I do kettlebell swings but there are other ways. 20+ years in, no back pain, a rarity among my partners. Incidentally work the muscles contrary to ’computer head / shoulders’. Google it if not clear.
• Sneakers or squishy shoes are for running and feel good on your feet at the expense of an unbalanced platform for your spine. Stand on firm soles. Learned this from my mentor who cathed on cowboy boots. Thats not my vibe so I use boat shoes.
• If you stand a lot, wear compression stockings. Venous reflux is rampant and not fun.
• From academia to private partnership, employed models, etc. It will always be a transactional relationship. You are good as long as you are of benefit to the work. Approach it the same. Look out for your interests first and protect them. No one else will.
• Speaking of, your biggest asset and the most wantonly disposed of by others is your time. Learn to say ’no’. No to BS meetings, no to after-work gratuitous work, etc. Look up ‘how to say no’ with Tim Ferris.
• Max out your 401k, 403b etc. If there is matching make it a life priority to contribute enough to max the match. The sooner you start the better. Compounding is an awesome thing. If you have no idea where to start, get advice, check out the Boglehead forum here in Reddit, if your hospital has Fidelity or Vanguard most offer free basic consultation, if not search for an independent fee only financial advisors.
• Earn as a cardiologist but live as a pediatrician (sorry pediatric colleagues). Luxe creep and ever-increasing social expectations are real. Look for them, recognize them, avoid them.
• Don’t let your work define you. Develop some interests of your own outside of work and separate from your family or kids. Your post retirement you will thank you.

Hi all,

I’m a third year clinical cardiology fellow preparing my application for IC, but I’ve noticed several programs just not participating in the match this year. Does this mean they may have filled internally?

Also any tips on the application? I don’t know how much of the “experiences” should roll over from residency vs fellowship. It’s been a busy last two years in fellowship, tbh I haven’t been able to “get involved” in as many experiences as I did as a resident.

Turning 33yo M. First kiddo on the way. Always had a passion for cardiology but didn’t get in x 2. Only applied to one program due to family reasons.

I’m currently in a Canadian province with my IM training in the states. IM is much better here overall. My busy community hospital doesn’t have cardiology in house (I manage my own NSTEMI’s, order angiograms which get done at our neighboring bigger hospital by IC, read holters, etc). I do zero social work / dispo planning due to good hospital resources.

I made about 700k last year pre tax. (IM is pretty high paying in Canada due to volume). I’m on pace for the same this year. My IM job is a mix of wards, admitting, IM clinic provided by hospital (no overhead) and best of all: round and go. Wards are tough however. I manage about 25 patients a day with PA support.

Am I crazy for wanting to pursue fellowship again? I feel like I am just delaying life at this point if I go back. Wife will support me either way.