COMMENTARY

A Career in Cardiology: Advice From an EP

John Mandrola, MD

Disclosures

February 01, 2017

Editor's Note: Given the popularity of psychiatrist Dr Nassir Ghaemi's letter to medical students on choosing a specialty, we asked two cardiologists what advice they would give to anyone contemplating a career in cardiology. Read the companion piece by Melissa Walton-Shirley, MD: "To Be or Not to Be a Cardiologist."

Dear Learner,

I hear you are considering a career in cardiology. Great. We need more young people to care for one of the world's most common ailments.

The first thing to know about cardiology is that you don't have be a genius. My wife, Staci, who is a palliative-care specialist, says (lovingly) that I have accomplished a lot with little. It's true. I was an average student. I don't easily get cartoons. I'm terrible at Scrabble. And I'm still trying to understand exactly what a P value is.

Cardiology does require hard work. There's much to learn. And heart attacks know no schedule. Showing up early for rounds, staying late, reading lots, following master clinicians, and simply being curious are far more useful traits than innate intelligence. A wise old urologist once told me that B students make the best doctors.

Electrophysiology: More Than Procedures

I am an electrophysiologist (EP) in my 21st year of private practice. You may wonder; would I make the same choice again? Yes. Electrophysiology is as beautiful now at age 53 as it was at age 33. EP blends surgery and internal medicine—we actually cure people. You have to master catheter-based procedures and surgical techniques (yes, I cut and sew and use a Bovie). When a pathway supports a tachycardia and you burn it, you haven't managed the patient, you have cured him. But our job is much more than procedures. The doctoring part requires listening, examining, and then putting these skills together to make diagnoses and treatments. The heart rhythm is often a window onto the overall health of a person.

I call myself a "trained observer." A friend recently thanked me for saving his mother's life. How? I wondered; I hadn't done a procedure on her. He said every doctor who saw his mom told her to quit smoking. She kept on smoking. One day over a decade ago, I observed aloud that it smelled of smoke in the exam room. My friend said that his mom thought to herself, if it smells that strong, I have to stop. She never smoked again. Her cycle of emphysema exacerbations and angina hospitalizations stopped. Ten years gained—from mere words and observations!

I tell this story to assure you that cardiology has at its core basic human relations. You don't, you can't, give up basic primary care. It's a bit of a paradox. Despite the wizardry of technology and all the wondrous things we can do in the intervention suites, the need for personal connection has grown even more valuable. The more we learn about heart disease, the more we understand that the best therapies for common maladies like atherosclerosis and atrial fibrillation are good food, exercise, sleep, and a joyous fulfilling life. You don't deliver those things through catheters. A patient recently asked me if I was his cardiologist or psychologist. We were discussing ways to help him find a life-work balance so his heart would skip less.

Knowing When to Say No

The hardest part of my job has changed over the years. When I started, the most vexing problem was not having enough to do for patients. I remember watching an older man slowly die from heart failure. His QRS complex kept widening and his left ventricular function gradually worsened. This was before cardiac resynchronization devices. Now, it's likely a CRT device would have arrested his spiral of organ failure.

That said, the explosion in new technologies has introduced a new problem: we can do (many) things to people, but should we? As a specialist, I'm often the one to say, no, this patient is too old or too sick for a final procedure or surgery. The correct diagnosis is that the patient is dying, and it's our job to be truthful and help provide comfort at the natural end of life. All patients die, and increasingly, the specialist is tasked with diagnosing when it's time to change goals of care from life-prolonging to comfort care. At 3 PM, you may be in an EP lab fixing a 20 year-old with an aberrant pathway, and at 4 PM, you could be sitting bedside holding hands with a dying woman and giving comfort to her family.

Perpetual Student With Many Masters

Two final points on cardiology. One is the need, the desire, to be a lifelong learner. In training, you bustle to learn the techniques of the time. These are new to you. You start practice as the local guru. That status has a short shelf life. The pace of innovation is fast and soon a new technique will come along. When I started, neither AF ablation nor CRT had been conceived of. Now those two procedures constitute most of my practice. I had to become a student again. I traveled the country and world to learn these new techniques. And even now, I'm teaching myself a novel way to pace the heart (His-bundle pacing may transform a decades-old way of cardiac pacing).

Then there is the matter of surviving in the new world order of medicine. When I started practice, doctors were the apex predators of healthcare delivery. Leadership in hospitals came from doctors—often specialists. That's changed. Now, the doctor serves many masters—from hospital administrators, compliance officers, third-party payers, and coders. These distractions from patient care will be less of a problem for you than it is for us older docs—you will have known it no other way.

An older family doctor and I lamented the new healthcare delivery system in the doctors' lounge last week. His advice was sound. The successful person, he said, finds a way to make it work. It being doctoring. In her wonderful book, It's Easier Than You Think: The Buddhist Way to Happiness, Sylvia Boorstein, a psychotherapist and mindfulness-meditation instructor, teaches that success and happiness come from managing as gracefully as possible. Whether you choose cardiology or a different specialty, managing gracefully will serve you well. I recite this phrase often during the solitude of my daily bike ride to work: "Manage gracefully, today, John."

Good luck,

JMM

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