To Be or Not to Be a Cardiologist
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 John Mandrola, MD: A Career in Cardiology: Advice From an EP.
I’ll begin with an apology. This will be no match for the beautifully written philosophical advice offered by Dr Nassir Ghaemi. “When you are called, you don’t choose. You just know. You don’t have an option,” he wrote. How lucky or blessed is the individual who knows precisely what they want to be, but I’ve come to accept that genetics and socialization play a heavy part in our life choices. Deciding on a specialty can be an agonizing process for some. Although we hope that our daily grind will be an indulgence 20 years down the road, we secretly fear that it might become drudgery. It is best to examine our attributes (or detriments) early on, pair them with our life goals, and find a career that respects both.
Are You an Adrenalin Junkie?
I’m a firm believer that possessing the adrenalin-junkie gene is a prerequisite to thrive in the world of cardiology. It makes you tolerant of a life of interruption and inconvenience. I sutured my first bloody patient when I was just 17 (an opportunity that is virtually nonexistent in the medical legal world of today). I knew from the beginning that I’d rather hang out in the trauma room in the ER than anywhere else in the hospital. “Room 9” was the kind of place where dope dealers bled out on a gurney while 12 people in gloves and eye shields worked furiously to save them. It was a place where innocent motor-vehicle victims clung to life or lost it as the last grain of sand fell through the golden hourglass. I wished no one any harm, but if harm came his or her way I wanted to be at the interface and I wanted to make a difference. I did not swoon at the sight of blood. I ran toward it. So why didn’t I choose emergency medicine? The abundance of adrenalin in the ER was certainly attractive. I could envision a career living behind a firewall that held panic at bay, emulating the calm cool exterior of ER attendings while the entire world was coding, choking, and dying. But there was little follow-up on how patients fared as a result of my care unless they were frequent fliers. I observed a high degree of burnout among ER physicians. That and the incessant trail of pregnant 14-year-olds with pelvic inflammatory disease and drug seekers who had “accidentally” flushed their oxycodone turned me off.
Meshing Capability With Desire
The best physicians know what they don’t know and what they can’t do. It’s important to mesh your capabilities with your desires. I opted for internal medicine as a ploy to delay my specialty choice a little longer, and that’s not a bad idea for an indecisive medical student. It gives you more time to examine your talents and limitations. The news that I’d chosen internal medicine reached the ears of one of our thoracic surgeons. “You are a traitor,” he said, without smiling when he met me on the pedway. “I thought you were going for surgery.” I did not take offense. I was tremendously flattered. There was no question that I have a tolerance for long hours that surgeons appreciate, and my small hands had the dexterity for surgery. I salivated at the thought of commanding an OR, cannulating for bypass or delivering that electric spark to a sleeping heart, but I lacked the mechanical ingenuity and any talent for basic geometry. I am not a carpenter like my brother or my father. Sadly, I accepted that I could no more be a great thoracic surgeon than a successful Victoria’s Secret runway model.
The Impact of Fate
It’s hard to differentiate between happenstance, divine intervention, and what others call fate. It’s even more difficult to let yourself be guided by it, but when opportunity presents itself, you should consider it. It’s the biggest reason I’m a cardiologist today. A few hours before I was about to sign with a large internal-medicine group, I got a call from our chair of cardiology. “You are not going to be happy as an internist,” he said boldly as I waddled though the door in my red maternity dress, the only one that fit and the last one I could afford. Should I cancel the dinner that was planned to celebrate my future career as an internist? How could I be a cardiologist when I couldn’t even interpret an ECG at the time? I said a prayer and my inner voice spoke to me. I thank God that I listened and took an opportunity that I had no hint was coming.
Serve Your Passion
If you choose a career in cardiovascular medicine, you will still have choices. You can join the concrete world of coronary intervention, indulge in the abstraction of electrophysiology, or engage in the engineering and geometry of percutaneous valve replacement. You can choose a noninvasive world where nuclear studies and echocardiography abound. You could also practice office cardiology (be warned that complex patients and unexpected walk-ins can ruin a cushy schedule). In my training days, I would fearlessly and stupidly stick anything. I did not give a second thought to placing a central line in a patient with a prothrombin time of 30 (no INRs back then). Thoracenteses, paracenteses, and spinal taps were my bread and butter. Invasive cardiology satisfied this love for procedures without the fear of being undone by my limited 3D spatial orientation. I figured the aorta was the only interstate to the coronaries, so I could surely manage to find the heart. The fast pace of cardiology offers new, lifesaving modalities every 5 years (a trend that has continued for nearly 3 decades). Who could be bored with transcatheter aortic valves, MitraClips, left ventricular assist devices, and new heart-failure and anticoagulant drugs in our toolbox? I have not been disappointed even after I retired from the cath lab. I still derive an intoxicating satisfaction from diagnosing and referring patients. My last greatest thrill was when a long-term patient received a heart transplant.
Is cardiology conducive to having a family? I wanted children for as long as I wanted to be a physician. It requires a lot of planning to be a parent and a cardiologist. My advice is to surround yourself with people who are willing to help. Backup plans A, B, and C will sometimes be exhausted so have a plan D just in case. As a fellow, I was about to bolt out the door to the cath lab when I noticed spots on my 4-year-old’s face. Chicken pox blew through all my contingency plans. Innovation and perseverance are key in any profession, but you will need more of it to be a parent and a cardiologist whose schedule is full of procedures that took days or weeks to precertify and plan. You must choose a soul mate carefully. The greatest attribute in a life partner is not their tolerance of your profession, it’s their understanding that you are your profession. It’s finding someone who knows that asking you to stop practicing medicine would be like asking a musician to put down the guitar. Reciprocate by realizing that family life is not all about you. Sometimes those outpatient echoes, nuclears, and Holters can wait. Finally, if you choose cardiology you must accept that cardiovascular disease is the harbinger of death for more human beings than any other. Remember that everyone has to die sometime and that death is not always the worst thing. Be prepared to fight for more life for your patient when appropriate but to also comfort and counsel them when it’s time to let go. At this point in my career, 27 years down the road, I am still a proud and grateful cardiologist. My best advice is to follow your passion. Seek what thrills you. Chose a specialty that sustains you. Ask advice, say a prayer, and hope for the best.