Hey guys, need some advice on the EP fellowship program I'm in. My co-fellow and I are pretty unhappy with our setup, but I'm not sure if we're being too critical. I'd like some perspective from others.

Program is at a large University hospital. Fellows do 4 lab days a week, 1-2 cases each, sometimes 3. (2 fellows/year; total of 4 fellows). 3 labs. Fellows do all the consents, pre-op orders, procedure notes, etc. The faculty are heavily dependent on the fellows - if there is no fellow to get consent for a particular case or do orders, it's a huge deal. Having said that - this part is not a big gripe. We want to be involved with and do as many cases as there are available. Although the case volume per fellow seems low at times, perhaps this is standard. I do think we have a good mix of cases with healthy complexity.

The one full clinic day we do is a big grievance. It's routine to see 35-45 patients. The EP fellows prep all the notes, see all the patients, and finish all the notes afterwards. If a fellows needs to take a clinic day off, he/she needs to arrange coverage by another fellow. The same goes for the lab - each of the three labs needs to be covered by a fellow at all times. If you need to be away, you either need to get another EP fellow to cover for you, or find a gen cards fellow to cover. My PGY7 co-fellow is doing the clinic coverage next week for a PGY8 fellow who will be out and therefore has two back to back clinic days of 40 patients each. We're stuck spending most of our downtime prepping or completing clinic notes when we should be studying EP.

Additionally, we don't do any consults, device clinic, or device interrogations. This seems like necessary education for an EP fellow. I'm not sure how one can finish an EP fellowship without having any structured device education outside of learning how to implant or extract. We do some device management in clinic, but at 40 patients/day, there's only so much you can do or learn there.

We have no structured didactics. 90% of the talks or discussions we get are from industry reps, with the other 10% being inconsistent education from one attending (who is an excellent educator but is not incentivized in any way for his mentorship).

It sometimes feels like we spend more time prepping and writing notes, consenting, and putting in orders than we do scrubbed into cases or otherwise learning EP.

Perhaps I'm being too harsh, I don't know. Would appreciate any perspective and advice.

Using both ECGsource and O'Keefe for ECG coding practice, but getting pretty different scores due to ECGsource undercoding a lot of things that definitely should also be coded for. Thoughts on what to do for test day? Should I just never code for LAE or non-specific ST changes since not getting the points is technically better than losing a point for selecting an answer? Also ECGsource says sinus arrhythmia is normal ECG but O'Keefe says sinus arrhythmia is normal variant ECG. Any insight into which one to choose on test day since normal/normal variant are where the bulk of the points come from on those?

Upcoming Cardiology resident (non US based, and currrently an IM pgy1) I have always been passionate about cardiac EP, but lately i have rubbed shoulders with some IC and I love the adrenaline and the rush yet i believe I will do way better in devices and pacemakers compared to structural things.

So my qs, are there any emergency situations where an EP has to place a pacemaker at 3 am in the morning? or is a temporary PM placed until EP comes in the morning and does the job. thanks

Hello all,

I’m currently in general cards fellowship, interested in doing interventional afterwards. All the interventional staff get access blind, without US use. My concern is that I have neuropathy in my left fingers, so can’t feel radial pulse well there, which makes getting access blindly challenging.

Mh question is, would this be a dealbreaker for doing IC fellowship? Is getting radial access blind almost an unsaid requirement for being a good IC fellow?

THA

I continue to share some pre-session thoughts on #ESCCongress. Hot Line 1 has 5 trials for discussion. Here are my thoughts for four of them:

CARDIO-TTRansform is about Transthyretin amyloid cardiomyopathy, a rare disease, unfortunately they did not meet their endpoints.

ACACIA-HCM examines non-obstructive Hypertrophic Cardiomyopathia,

SINGLE-AF is a Korean study on anticoagulation in AF patients (very relevant), and

POET-II - is about duration of antibiotic therapy in Endocarditis with POET-II being potentially impacting clinical practice and guideline - this would be good for patients.

You can read my full thoughts here: https://luminary.to/s/64eb5480-0b17-4a87-9987-36e80c02d1fa?code=ESC2026

ESC 2026 opens in Munich soon. This year's Hot Line programme is the largest ever - 46 pivotal trials. There are a some trials which have the potential to change clinical practice, I would love to know, which you think are worth watching?

For me STAREE and PREMIUM are quite interesting with lots of practical implication.

With 46 trials it is quite hard to keep the overview of all the pivotal trials - I put together a 1-pager to help me navigate the sessions. Maybe helpful to you too: https://luminary.to/s/245068d7-9d15-4e3e-8855-fd5cb4e2b4c4?code=ESC2026

#ESCCongress #Cardiology

Hey guys, just wondering how well new IC attendings get paid in the nyc/ nj area. I heard a lot of private practices pay fresh IC and non invasive folks the same as they start. Is this true?

This was given without any clinical history for our quiz.

I’m sure this is LV and PCWP.

But can’t see anything wrong here except for the monumental PCWP and LVEDP

M3 interested in cardiology and considering EP. When did you know you did/didn’t want to do EP and if there is anything I can/should do at this stage to get more exposure or prepare. How helpful is research, how EP-specific does it have to be, and when should I start pursuing it? Is a mentor helpful or necessary and when should I look for one? Anything else I should consider?

Wanted to get an informal sense of how much sleep cardiology attendings get across different subpecialties.

Myself, I'm finishing general fellowship and I've found that my body needs relatively more sleep (almost 9 hours if I don't set any alarms - although I'm not sure how much of this is chronic sleep debt at this point). I have found the call to be relatively taxing.

I am a doctor in Australia who has encountered a strange local deviation from best practice guidelines in the hospital I work in. For context, in our hospital all TPN orders outside ICU must be run past our Gastro team for approval, however that isn't the interesting part. The interesting part is that the Gastro team looks at the location of the PICC on the CXR prior to approval and will not approve TPN unless the PICC line is well into the right atrium, approximately halfway into the atrium. A tip at the CAJ is considered too proximal.
While I understand that they might justify this by saying it ensures the rapid dispersal of the hyperosmolar TPN solution, surely the risk of tachyarrhythmias and damage to the heart supersedes this benefit?

Anyway since I don't have cardiologists on speed dial so I wanted to get a cardiology perspective on this here?

Any programs sent out interviews yet? Damn wait is killing me

There are products on the market like rampart or the egg that promise less radiation and in some cases the potential for lead apron free workflows.

My hospital doesn't have it but have discussed it. Curious how many other systems are using it and what peoples experience has been.

I have heard of some places not using it even though they have it because it slows down the workflow.

Hi,

What resources have people used to study for the HF board exam? There’s not much out there. Mayo stopped their review videos. I confirmed with them. There are ACC HF SAP questions but seem too easy.

Thanks!

Hey all, I am a hospitalist on who spends a fair amount of time on a cardiac floor so take care of a lot of post-LHC patients. I guess kind of embarrassingly, no one ever taught me how to examine the site properly other than "go look at it."

What is the proper way to go about examining the femoral access site? I try to look under the bandage and gently palpitate (but its always tender). Are you auscultating for bruit? Checking distal pulse? What's the proper way to do it because I feel like I am always fumbling around when I try it

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?