Medical Specialties - Cardiology (4 Sep 2024)

SPEAKER_01 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal for live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. Today I'm delighted to be joined by Dr. Anda Bulaga, who I'm sure you will have heard many of her podcasts. She is also on the training members committee, and she is a cardiology trainee in the south-east of Scotland. Andrew, welcome. Oh hi Marilyn and thank you very much for the invitation. Thank you for coming. So, as some of you may have heard, I am also a cardiology trainee, and this episode is dedicated to cardiology training. And Andrew and I are both hopefully going to tell you about how amazing cardiology is and why we went into it. So, Adna, I guess why did you choose cardiology?

SPEAKER_00 1:27

That's a good question. I think my passion for cardiology really started back in medical school. And really one of the main reasons was one of the my mentors then, one of my supervisors during clinical training at Dundee University, who was a cardiology consultant, but also very interested in medical education. And he was one of the people who set up the harbiginatra, the ones that we use in cardiology teaching, particularly for heart sounds, lung sounds. And he was very passionate about his work. And I remember sitting in his cardiology general clinics and just observing his interaction with patients. And I really, really kind of was inspired and admired that. This was Professor Stuart Pingle, who was a consultant cardiologist in Dundee. I did a couple of rotations in the cardiology unit at Ninewell's Hospital in Dundee and also CCU. And I must say the management of an acute myocardial influx was very, very impressive for me at the time, and I really enjoyed observing the journey of those patients. As I went through my training, including foundation training, war medical training, did my research, I think I grew to love cardiology even more. And really what I realized with cardiology is that it gives you such a variety to your day-to-day work. So I absolutely love that one minute you can, you know, you manage patients on the wards, go on your ward job and see people in CCU acutely on the well, and then you have the opportunity to look at some exciting cardiac imaging scams, get enrolled in different procedures, and also manage patients with chronic long-term conditions. So I think it's the variety that really attracted me to cardiology and the people I've been working with. Well, what about you, Marilena? Yeah, I totally agree.

SPEAKER_01 3:07

For me, it was in medical school, I found revising the cardiovascular system the one that just didn't tire me. I thought it was so interesting, so exciting. And then when I started going into clinical attachments and working as well, what I loved about cardiology is the variety. You want to treat acute patients, you can. You want to treat chronic patients, you can. And there is just such a big scope of things that we can do to make patients feel better, whether that's more practical. At one point I did toy with the idea of being a surgeon, which, you know, I'm quite glad that I didn't. I feel very happy in my decision. But we have been considered a surgical specialty because of all the interventions that we can do. But again, now I'm learning a lot about cardiac imaging, which is much less invasive, but so exciting. So I think I just love all the different things that you can do in our specialties.

SPEAKER_00 4:03

Yeah, I think we're to do one of those a day in the life. You'd just be surprised by the variety of things we get to do in one day, and particularly in our training as well. So I really, really enjoy that.

SPEAKER_01 4:14

Definitely. I think you're totally right. It would be very difficult for us to do a typical day. But should we maybe talk about, you know, a typical week in training and then how training varies depending on how senior you are when you kind of choose your subspecialty?

SPEAKER_00 4:30

Sounds like a good idea. So I will describe briefly what I'm doing at the moment because I'm currently working in District General Hospital as part of my training attachment, Border General Hospital in NHS Borders. And then I will also tell you when I started last year as an SD4 how my day was. So for the moment, my day-to-day work is both in cardiology but also in general internal medicine as a higher specialty trainee. So during in hours, so night to five, I usually work with the cardiology team. So we start the day by doing the CCU word round and seeing new admissions and also patients that have been in CCU for a few days. Some of these are waiting to go to have a procedure such as pacemaker or a corner and angiogram perform. So we'll see the new referrals as well, both in the CCU that were admitted overnight, or patients who are waiting to be seen in the emergency department. And then I'll go and see the patients that have been in for a kind of more long term, for example, those who are being treated for endocarditis. After that, we usually have kind of a meeting with the team, the consultants, if necessary, the electrophysiologists, the echosenographers, and we chat about any cases that need to discuss. We do have an MDT on a Friday as well, where we go in detail about scans for inpatients and also outpatients. The afternoons are good, so most of the time I do outpatient clinics where I see a variety of cases on the general cardiology clinics. So again, people presenting with a suspected horny disease and stable angina to those who have a long-term follow-up for vagular heart disease or underlying congenital heart disease. I join sometimes a consultant for transistophageal echocardiogram procedures. So I'm currently learning that in conjunction with learning to perform echocardiogram as transhoracic echocardiograms towards my British Society of Echocardiography accreditation. During out of hours, when I'm on call, I am on call as the medical registrar, so on call for a variety of specialties and hold also the cardiac rest breep, and I do the same at weekends and overnight. Currently, I spend one day in the Royal Edinburgh infirmary doing my specialty day, where during the morning I join the consultant in the pathogisation laboratory, and I'm currently learning to perform diagnostic coronangiograms under supervision. In the afternoon, this is my echocardiogram session where I usually scan patients who come from the outpatient department and usually get to scan four or five people and then report and get the scans checked by the echosonographer, so that's working towards my accreditation. So this is currently my kind of week in cardiology in the District General Hospital. Last year I started my ST4 rotation, so all of us, the trainees, rotate around. But last year I started at the Royal Infirmour of Edinburgh, so this is a tertiary university centre, and the week was very, very. We had weeks on call where we would work on the ward during the mornings and help the ward team to see all patients, can send patients for different procedures and investigations. In the afternoon, I would hold the on-call bleep and get referrals and questions and queries on the bleep from different special teams across the hospital, see patients in the emergency department or the RTU department. I would cover and so the tertiary centre and another two hospitals in the area. During non-call and non-on-call weeks last year, my week was pretty buried. I would do about two or three outpatient clinics during the week. I would join the CAF lab session, I would join the pacing session and do some echocardiography as well and MRI reporting. And all of these were supervised sessions towards training. On Fridays, we normally have an afternoon education preceded by the multidisciplinary team meeting where we discuss interesting cases. And the afternoon education is really our training afternoons, which are national in Scotland, or local teaching, which is usually based on interesting cases. So again, as you can see, quite varied. There is opportunity through that to teach undergraduate medical students that join us on in the cardiology department and also work with your team, including foundation doctors, internal medicine trainees as well. What about you? Does it sound burned for you? I know you're currently undergoing research.

SPEAKER_01 9:03

So at the moment, I'm in my second year of my PhD, so things are slightly different to my clinical rotation. For us, it's slightly different in England in that for the first couple of years, we tend to be based in a district general hospital, in which case we would do exactly what you said. So, you know, cardiology during the day, and if we were on call, we would be the Med Regon call. And our job there is to learn the basic skills of doing a chronic angiogram, start building up your echo skills, your pacing skills in the CAT lab, and then ward rounds on CCU or on the general cardiology ward, as well as a variety of outpatient clinics. And then once you get to ST5, you can choose what subspecialty you want to go into. And I know we're both not quite there yet, but in general, you can choose whether you want to do intervention. So that would be someone who the majority of their work would be in the cath lab doing angiograms, angioplasty, and some interventional cardiologists are now doing tabby procedures or more complicated procedures such as those for chronic total occlusions. You could then choose for pacing to be your subspecialty, in which case again you'd be in the cath lab and you might do electrophysiology studies or put pacemakers in. Another one is heart failure, or you can have imaging. And depending on, you know, the subspeciality that you choose, you need to acquire different skills. And the whole point is that the more junior you are, you get an exposure to all the skills that you would potentially need for each sub-speciality, and then you choose which one you go into. And then as you become more senior, you focus more and more time on your chosen sub-speciality. But again, the on-calls are very varied. It depends when you're in a tertiary hospital. You only do cardiology on calls, so you will see patients with cardiac problems from a variety of different specialties, as opposed to when you're in a district general, you would see kind of all the medical patients.

SPEAKER_00 11:04

And what I find very interesting, there are still other branches that are underdeveloping through all these subspecialties. So things like cardioncology is growing a lot, particularly when Russ and Scotland as well. We have specialists and congenital heart disease, maternal cardiology as well is becoming kind of a big area when there is a lot of research undergoing. Things are always changing and there is always opportunity to diversify your knowledge but also your skills.

SPEAKER_01 11:31

Yeah, no, I could not agree more. That brings me quite nicely onto my next question, which is what advice should we be giving to doctors who might be interested in following this career path? And for me, based on what we've just said, there is so much out there is just about getting as much exposure as you can, whether it's applying to do a rotational job in it, or if you haven't been able to get rotation in cardiology using the taste today that you're allowed to have more exposure into cardiology. And if there's a helpful registrar that you may have met, trying to ask if you can shadow them for a while, just to see exactly what options are available, because there's lots of them. What would your advice be, Ember?

SPEAKER_00 12:18

Absolutely, I completely agree with you. As you said, trying to get a rotation either during your foundation training or inter-medicine training in cardiology is a great idea just to be there to see how these patients are managed and to see the diversity of things that happen in cardiology. I think for me it was getting in touch with people and speaking to people and finding out what they do and getting to work with them on different projects from smaller quality improvement projects during early years to bigger research projects and developing an interest that has really, really helped. Similarly, getting involved in medical education opportunities is very important. I remember as a foundation doctor or an IMT, I was helping with the undergraduate teaching was part of the cardiology curriculum. I really enjoyed that partly because I also got to revise some of these things, particularly when we go back to the physiology, which is so so important. The research, so again, going back into project, I think many people will be aware that research is very developed in cardiology and there is a lot of project going on wherever you are in the country. So getting involved in those and starting to acquire some of those skills will help you in your future training. But ultimately, developing the skills of if you organized doctors from early years will be the help. Whatever job you're doing. So acquiring those skills are very important because they're all transferable later on as a medical registrar and a cardiology registrar.

SPEAKER_01 13:48

Definitely. And I think you've picked up on something that's really important for us to mention. I have a lot of juniors asking me, oh, but you know, I don't like research, or I'm not sure about education. And you know, to be a cardiologist, you need to do a little bit of everything. And I do think that's really the case. And the more you speak to people, the more you shadow them, the more you see how different people work, you'll see that everyone just kind of creates their own path. We're lucky because there are so many different opportunities that we have, whether it is research or medical education or your practical procedures. But I don't know a single cardiologist that has the same job plan as another. And it's just about seeing which of the skills that you want so you can take those forward. Yes, exactly.

SPEAKER_00 14:36

And I know many examples of my colleagues who perhaps were a bit anxious to go into research or teaching, but absolutely loved it and are such impressive and uh skilled teachers and academics. So you never know where you'll find your area of interest and taking advantage of those opportunities and really discovering what you like, both for your training but for your future career, I think is very, very important. So I'd really encourage people to be open-minded towards all these opportunities to help them decide what makes them get out of bed in the morning.

SPEAKER_01 15:14

Definitely. And it's exactly about what you said, reaching out to people. People want to work with people that like what they do. And if that's doing an audit, just so you have something on your CV, you know, to show that you are committed to the specialty, that you've taken that time to do it, every little helps when considering applications and future careers.

SPEAKER_00 15:37

Yes, and I must say all these people have very busy schedules, but I always constantly stay impressed by how, you know, I was thinking about my colleagues about my PhD supervisors, Professor Nimbi, Professor Mills, how they'll always find time for those who show interest just to share their passion with people. So I think locking on doors and sending that email if you're interested and to find out more about project, you'll find that people are more than happy and will welcome you with open arms.

SPEAKER_01 16:07

Yeah, I could not agree more with that. So, in case we haven't convinced you enough about how amazing cardiology is, I think we should try and do that by discussing an interesting case that we may have had. Obviously, you know, abiding by patient confidentiality. And do you have any that spring to mind?

SPEAKER_00 16:26

So you did kind of put me on the spot, but I will tell you about this case that I remember very, very well from very early days actually, when I did my foundation year one job in cardiology. It was a case of a patient who had rheumatic valve disease and underwent previous valve replacements. I will not remember all the details about the valves and when the procedures happened, but this was a summary of the case. The patient had been admitted following her surgery, which was a while back, with kind of constitutional symptoms, and there was some suspicion of endocarditis, but also had real evidence of hemolytic anemia, which we know that can happen in patients with mechanical valves. And this patient had a very long course of treatment with antibiotics, many, many multidisciplinary meetings with the infectious disease team, cardiology team, cardiothoracics team. She spent many months in hospital and undergoing treatment when I started the four-month rotation and she was there when I left. And you can imagine what a four-month hospital admission can do to somebody who's already unwell. But I remember how remarkably well she's done towards the end of this. And to my biggest surprise, probably, I got to meet the patient in the clinic that was doing a few years later, and she was doing so great. That kind of case type came to mind because it showed that this long-term management in cardology and the cases we deal with because we're always used to this kind of rapid admission discharge, but it was great to see how that multidisciplinary work had done so well for this patient. What about you, Marilena? To be honest, I ask you this question.

SPEAKER_01 18:11

I've been part of this, but I want to tell you about two recent cases that are very I won't go into a lot of detail, but for example, the kind of things that you can do when you're on call. I was on call this weekend and I got in District General Hospital, so I was just seeing general medical patients, and I got asked to see a relatively young chap who came in with a four-week history of abdominal swelling and shortness of breath. To cut a long story short, he clinically had pitting edema up to his umbilicus and was describing orthopnea and paroxysmal nocturnal dyspnea, and had an excise tolerance of about five meters. So I went, got the echo machine, did a very quick echo, and you could see that he had an ejection fraction of about 10 to 15 percent. So I immediately started him on some Ivy bruisemide. Within half an hour, he had diarrheased 3.5 liters and was already feeling better. So it's not a particularly exciting case in that he will need a workup as to what's caused this. I suspect he'll need a cardiac MRI at some point down the line, he needs optimization of his medications and so on. But I guess it's just to highlight how acutely you can see patients and also make them feel better with something that's not necessarily invasive. You know, a quick echo can give you a diagnosis or the start of a diagnosis for you to help that patient on their treatment journey.

SPEAKER_00 19:50

Very interesting. And what about any clues on the etiology of this?

SPEAKER_01 19:55

They were known to have consumed alcohol to excess. On their echo, there was moderate MR and moderate TR, dilated right ventricle, biatrial dilatation. So I think it's most likely going to be multifactorial, which is why I think when they're optimized, they're most likely going to need an MRI scan.

SPEAKER_00 20:17

We both described different cases, one more chronic management, one more acute that will also need involvement from multidisciplinary teams and will follow up in clinic. Yeah, I think this is what makes me very excited every day, just the variety of these cases.

SPEAKER_01 20:34

And the fact that we gain so many skills through our training that are so helpful, whether you are working as a cardiologist or as a general medicine doctor. So if we maybe discuss the skills that we need, and and I think we should maybe discuss not the skills that we learn in training, but the skills that you need to be a I don't want to say to be a good cardiologist, but what skills do you think you need to undertake training in cardiology?

SPEAKER_00 21:06

As you just said, I think all these skills are transferable through our special teams and through our IMT training. For a career in the this is the way I see it for a future career in cardiology or cardiology training for me is being hardworking and being organized, being efficient are very, very important because when I get that belief, it could be anything and it just keeps going. So having those skills is very, very important. The generic skills of being a good communicator and being a very good team player, knowing how to work with colleagues from a multidisciplinary team are very, very important because in cardiology we have so much of this MDT work and we always communicate within the specialty but also with our specialties, including the surgeons, including our medical uh specialties and community doctors. But really for me are those three hard work, efficiency, and being organized and really being motivated for what you're doing and showing passion for that. What's helped you most?

SPEAKER_01 22:12

I completely agree with what you said. I think the skills that I would add, which overlap massively with the skills that you've described, are the ability to prioritize. Because especially when you get referrals from other specialties, everyone thinks their emergency is the worst one from a cardiology perspective, and you need to be able to prioritize. And in keeping with that, is the ability to remain calm under pressure. Because it just so happens that just as in any specialty, but I think especially so in ours, a sick patient becomes more sick very quickly. And you just need to be able to stay focused and be able to make safe decisions under that pressure. Completely agree. And you know, you'll need that throughout your career, whether you do end up, for example, treating heart failure, which you tend to see more chronically poorly patients, but actually on your wardrounds, you will be seeing acutely unwell patients as well. But then everything else that you've mentioned, teamwork is imperative, good communication is so important. And most of all, you just need to love what you do. I don't think I could do anything other than what I do, and that doesn't necessarily make me a good cardiology trainee, but it makes me a happy one. And I think when we're happy trainees, everything else kind of falls into place as well.

SPEAKER_00 23:31

Exactly. It would be very hard to do it all other way. I see that in speaking to me and my colleagues that work with just how passionate everybody is and how dedicated to the work they are. And I think that's inspiring. We all just strive to do better and to learn. And it's lovely to be able to share some of that experience. Definitely.

SPEAKER_01 23:51

Andra, before we finish, I'm going to ask you a question. I have a lot of trainees asking me or telling me, like, I would really like to do cardiology, but I don't understand ECGs, or I'm scared I'm going to make a mistake with an ECG. I don't know if you have this, but I've had it quite a lot. And I by no means think I'm an expert at ECGs, and sometimes I don't have a clue what's going on. How do you react to that question? And what advice would you give to somebody that said that to you?

SPEAKER_00 24:22

So I would definitely tell them that just because I'm doing cardio training doesn't mean that I'm an expert and I know ECGs A to Z. And do you know actually, I'm so glad you added that question because I'm really fascinated by ECGs. And we have this 3D case with the team for very informal local teaching with consultants and fellow registrars. And there is always some interesting ECGs that come on. And it's amazing how much you can know and how much you can learn from an ECG. And honestly, that's what I find very, very interesting in cardiology. And I hope one day to really improve my knowledge of ECGs and be able to look at those kind of riddleships that are very challenging and understand what's happening. By no means that's happening at the moment. So whoever is considering cardiology but feels that's a barrier, we can reassure people from our experience that shouldn't be the case. Unless you're doing electrophysiology and you've done it for many years and you passed your exams and you're in the EP lab and you understand all the mapping systems and things. I don't think there's many people there that will say that they are absolute experts on ECG reading, but it's such an important and interesting tool and really encourage people to, if they want and if they're keen to develop their knowledge more just for reading, through life in the past lane, I always find a good for for some quick ECG tutorial. So yes, that shouldn't be a barrier, but the fact that you may even find ECGs interesting, I think it's important.

SPEAKER_01 25:58

Definitely. And I guess with that, the one thing that I'll add so that people aren't scared is that at the annual British Society of Cardiology conference, there is always a session on ECGs, and it is always full of doctors of all grades, including consultants, to discuss ECGs, whether they're interesting, difficult. And I think that's a sign of how much it's a skill that we all learn throughout our career, and it shouldn't be the beal and end all of our training or your decision to do our specialty.

SPEAKER_00 26:30

And there's so many interesting skills that you will acquire and learn. You know, consistency, practice, and educational learning. And I think it's just exciting to see how your knowledge and your skills develop. You know, looking back to a year or two years ago, speaking about ECOS, which is kind of my main focus at the moment. It's amazing how much you learn from being there, speaking to colleagues and doing this kind of yourself. Definitely could not agree more.

SPEAKER_01 26:57

And thank you so much for joining me today for sharing my passion for cardiology and hopefully for helping me inspire lots of other people to follow our career.

SPEAKER_00 27:08

Thank you very much. It's been lovely chatting to you and as you say, sharing some of our experiences through our training. As I always say, if anybody is interested and would like to find out more information, do not hesitate to get in touch. And we'll be happy to always help and advise.

SPEAKER_01 27:24

Definitely. And I'll put some websites in the show notes of interesting websites or resources that might be useful for you. Rick, thank you.