Healing the Heart as an Adult Cardiologist

Session 195

Dr. Tonia Singh is an adult cardiologist and today, she talks about how she tackles call shifts, patient cases, and life as a cardiologist.

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[01:05] Interest in Cardiology

Tonia’s dad had a bypass surgery when she was 15 years old. Her father, being a “fit”and active individual who was a brigadier in the army, ended up being diagnosed with severe three-vessel cardiac disease. He was 47 years old and had a three vessel bypass at that time. Tonia found it super interesting for doctors to be able fix something so bad and have him come back to them as the person he was before and do really well. Her father is now 80. This sparked her interest in cardiology. It was something that can lead to death, or can lead to a long, happy life and the things that the doctors can do to make that happen.

During medical school, Tonia liked the surgical specialties because she likes using her hands. She also had great surgical rotations, and got to be involved in some surgery. But she likes the whole longevity of knowing what happened to the patient 10 years later. And she found that was missing in the surgical specialties, especially the ones that she was exposed to as a medical student. She was also interested in nephrology, but then she ended up marrying a nephrologist. So she didn’t think it’s good to have two nephrologists in one house.

Ultimately, she found cardiology interesting physiologically and the idea that you could make a great difference in their life long term by taking good care of them. Then her cardiology rotations reinforced the fact that she loved cardiology and the variety of it.

[04:04] The Biggest Myths or Misconceptions About Cardiology

Tonia says that a lot of medical students and residents think of Cardiology as having a terrible work life balance where there’s hours and hours of work and constant calls. And also, it has a very macho culture.

Speaking as a woman in cardiology, Tonia adds there’s only 13% of cardiologists are women right now. And so, they’re a minority. But she thinks this is no longer true anymore as more and more women enter cardiology.

There are so many choices within cardiology. So cardiology is no longer that monolith of you’re going in for semis every night and you’re staying in the hospital till 9pm every night. That’s no longer true. So

[05:47] Types of Patients

Tonia sees patients all the way from 18 to 103. And she sees a broad spectrum of problems starting from leftover congenital heart disease issues that show up in my young patients. She sees a lot of pregnant women with cardiac issues. She sees some people interested in prevention who want to talk about their family history and want to make adjustments earlier in their lives.

The bread and butter of cardiology are people with hypertension, diabetes, hyperlipidemia, coronary artery disease, congestive heart failure, atrial fibrillation.

As they get into the geriatric population, they see the failing hearts, general deconditioning, and just dealing with people throughout the spectrum of their lives. And so, she’s seeing a broad variety of patients.

Tonia says she’s fortunate to work in a practice where she works with 14 men and she has partners who are electrophysiology (EP) interventionists. And if she needs anything for her patients, she can just ask for their help. Electrophysiologists are divided into electricians and plumbers. The electricians focus on the arrhythmias and the plumbers focus on all the blood flow problems.

[08:23] Traits that Make a Great Cardiologist

Tonia stresses that to be a good cardiologist , you should be willing to listen to their patients. You have to have the patience to take a good history from your patient and do a good physical exam. You have to be detail-oriented.

Sometimes you have to make major decisions, whether you want to send somebody to bowel surgery, or bypass surgery. Those are major life changing events for the patient so you have to be somebody who can make a decision relatively fast.

And also, you have to be empathetic. The patients have a lot of psychological issues associated with all the physical stress and physical problems they have. So you have to be able to work with that as well.

[09:31] Ratio of New Diagnosis vs. Existing Conditions

Tonia sometimes sees new patients who will come to her with symptoms that have not been figured out yet. They may have chest pain or shortness of breath or palpitations. And their job is to figure out whether these are concerning symptoms, whether they’re associated with a heart issue or not. But she also sees a lot of patients who have known coronary artery disease or cardiomyopathy, following patients with pacemakers and defibrillators. So it’s a mix of things. So every day is different.

[10:18] Typical Day

Tonia likes to start her day early. She’d be in the hospital by about seven. She would schedule a procedure usually first thing in the morning because it’s more convenient for the patient since most of them have to fast for their procedures. She’ll do cardiac catheterization in the morning, and round in the hospital on her patients that have been there for a variety of reasons.

And then usually, she has office hours. That could be like a full day of office or a half day of offices, depending on the day of the week. She usually tries to stay within one hospital. So she doesn’t have to travel between hospitals very often.

[11:37] Working With Your Hands

Tonia says there are very few people who are ambivalent about doing procedures or not. It’s something they enjoy doing or they just have to do this because it’s part of their training. And there is adequate time during fellowship to make that decision. So it’s not necessary to make that decision before you start fellowship.

She adds that what’s interesting when you’re a medical student or a resident is you get to go in and see what people are doing and see if that is of interest to you.

Therefore, if the sight of blood makes you sick, or what they’re doing is stressful, then you could take that as a clue that it may not be the best thing for you.

[12:41] Taking Calls and Life Outside of the Hospital

Tonia says taking calls is not bad right now. When she first started out, she was on call every third weekend. Now she’s on call every fifth weekend. Night call is about once a week. Because I’m not an interventionist, she doesn’t have to go into the hospital unless she chooses to go check on a patient. But her interventional colleagues are on call about one in seven.

Speaking of life outside of the hospital, she feels she absolutely has one. And that’s because she works hard to make that happen. She’s married and has two kids. She had one child during residency and one child during fellowship. So that was a busy time.

But she and her husband have always made an effort to get as much help as they need to be able to do the things they want to do. She adds that getting help is cheaper than getting therapy or getting divorced.

'You have only so much time in your day and you really have to prioritize what is truly important to you.'Click To Tweet

[15:17] The Training Path

After medical school, you do an internal medicine residency for three years and then you apply for a cardiology fellowship. General cardiology fellowship in most places is either three years or four years depending on the program.

Following which, you could do either a year of interventional, a year of heart failure, or one or two years of electrophysiology. You could do a year of cardio oncology.

There’s a variety of subspecialty training that you can do after you’re done with your cardiology fellowship and structural heart disease fellowship.

So that’s about six to seven years after medical school. Three years of Internal Medicine, and three years of Cardiology would be the minimum time that you would spend to be qualified as a cardiologist.

Cardiology is one of the longer fellowships out there post-internal medicine, and Tonia admits there have been multiple discussions about making it its own residency.

One of the reasons why many women sometimes choose not to go into cardiology is because the path seems more long, much longer. And there has been talk about maybe doing a two year internal medicine residency and then getting into cardiology as a three-year fellowship. So doing a five year combined program like vascular surgery does. But it’s still all talk.

[17:08] Overcoming Bias Towards DO Students

Tonia doesn’t feel like there is as much negative bias as people seem to think. She works with a bunch of osteopathic medical students, because the hospital that she works at has an affiliation with an osteopathic school. Two of her own medical students, who are also both girls, are both cardiology fellows now.

She thinks it’s just a perception, sometimes. And so, she encourages the osteopathic students if that’s what they want to do to be vocal about it early, look for opportunities early in residency. Interact with possible mentors and sponsors within cardiology.

See if you can get engaged in your research early with them. It doesn’t matter what subject you do your research on. The fact that you have knowledge of research that you’ve put the effort in, and that you’ve been able to create a finished product is important. It doesn’t have to be something that has to be published in circulation. It has to be just something that shows the rigor and effort. And having a sponsor or mentor who is familiar with that can help you get on a project that will go to fruition.

Speaking to other cardiology programs where you’re applying and having somebody do that beyond just your program director may also be a helpful thing.

[18:43] Message to Future Primary Care Physicians

Cardiology is now encroaching into internal medicine with cardio diabetes issues with the new diabetic drugs. There’s so much cross between diabetes and heart disease. And a couple of years ago, when they started using all those drugs, they were always calling their primaries to start this because it’s great for their heart, but they’re managing their diabetes.

So she advises future primary care docs to get familiar with the cross-section between all these other issues. There are so many new advanced therapies that they may not be comfortable with using. So collaboration and talking with your cardiologists is helpful.

'Collaboration for the patient goes a long way. Your cardiologist wants to help your patient just as much as you do.'Click To Tweet

[20:18] Other Specialties Cardiologists Work Most Closely With

The four most close specialties would be cardiothoracic surgery, nephrology, endocrine, and GI.

They work with cardiothoracic surgery because they send their patients who need surgery for a variety of reasons. Nephrology because a lot of their patients have chronic kidney disease. Endocrine, because many of them are diabetic. And finally GI, because they are using so many anticoagulants for their patients. They’re seeing way higher incidence of GI bleed than they ever used to.

[21:14] Is Heart Disease Slowing Down Soon?

From a diet standpoint, Tonia is sad to say that heart disease is not slowing down soon. We are still not quite where we need to be as a society in working on all those determinants for heart disease. Obesity has gone up. She sees younger and younger patients with hypertension, diabetes, and who have a BMI of over 45.

And all of those have actually gone up in her 18 years of practice rather than gone down. So just in her little world, beyond just the statistical significance, she’s sadly not seeing the improvement that she would hope to see.

She believes this is something that would need some major legislation and change in culture before they’ll see any change.

According to the statistics, heart disease has gone up. We saw a big drop from the 1980s and 90s, down into the mid 2000s until about 2015. But heart disease in men and women both is going back up again.

“Heart disease in men and women both is going back up again.”Click To Tweet

[22:24] What She Wished She Knew Before

Tonia says she wished she had known that they would have so many new treatments. They were barely doing stents when she started as a fellow. But now, there are all these new cardiac resynchronization devices. All those patients with heart failure who didn’t survive are now getting better with just medication. And so, she thinks this is a fantastic time in the history of cardiology to be practicing such a specialty. And so, she loves practicing it everyday.

'We have so many choices that we can offer our patients that can make them better.'Click To Tweet

[23:22] The Most and Least Liked Things About Cardiology

Tonia likes the variety and the fact that she has known her patients for close to 20 years. She has seen them go through ups and downs and improve and spend time at their grandchildren’s births and teach their grandkids to drive. and those are things they may not have gotten to see if they weren’t able to change their life. And she finds that really gratifying to see. She says it just refills your bucket to deal with all the other tough things they do in medicine.

On the flip side, what she likes the least is spending time with insurance companies because they have so many new therapies. And some of them obviously are very expensive. They often have to do peer to peer discussions about why somebody needs one of the new drugs. And she thinks those should be fairly straightforward.

One of the wonderful things about cardiology is they’re a very data driven specialty. They have multiple studies that are built on all the information they have. So usually it’s not hard to convince them but it’s just another barrier in the care of the patient.

[25:29] Major Changes Coming Into the Field

They are getting new therapies including a new lipid lowering drug coming out that’s going to be used twice a year. It’s great because the compliance issue is gone and you have great data.

There are all these devices they can put into people that can monitor their heart failure. Then they can just manage from home and they can take care of their heart failure admissions.

One of the things that is coming down the pipeline is that Medicare is now going to bundle every diagnosis into a bundle. And then they’re going to try to manage patients in a population way, which can be very challenging.

Being in private practice, she’s a very small minority of all cardiologists since about 16% of all cardiologists are an independent private practice. And so, it makes being independent harder because you need to be in that group with the hospital when you’re taking care of things like that.

[26:57] Final Words of Wisdom

If she had to do it all over again, Tonia says she would still be a cardiologist – 100%. Finally, she encourages students who might be interested in this field to see the various parts of Cardiology and see what makes you interested.

But don’t let anybody talk you out of it because they think it’s not a good work life balance. Because you have a lot of control over that. Maybe not during residency and fellowship, but after that, you can control how you spend your life. So don’t use that as a reason not to go into that.

And also remember, even if you have children, your children are only home for 18 years. Life is long, your career is long, and then you don’t want to give up on something that was your passion and then be resentful every day that you go to work because you didn’t pursue it. So pursue your passions.

[28:55] eShadowing.com

Medical schools understand that COVID has limited shadowing opportunities and virtual shadowing is going to be allowed on an application. They can’t prevent you from putting it on there anyway. But a lot of schools are going to accept that as shadowing. And so, if you haven’t yet, be sure to check out eshadowing.com today. Sign up for our shadowing every week Mondays at 8pm Eastern live, or you can watch the replay for the week to get credit for that.