What Does Community Pediatric Cardiology Look Like?

Session 83

Dr. Renee Rodriguez is a community-based Pediatric Cardiologist. She shares why she loves children’s hearts, a typical day, and whether she has balance in her life. Meanwhile, be sure to check out MedEd Media Network for more helpful resources.

[01:25] Interest in Pediatric Cardiology

The first time she realized she wanted to do pediatric cardiology was the second she started residency being her first rotation as a pediatric resident. For her, residency was the best thing that ever happened since she wasn’t in school anymore. She did another rotation but it wasn’t as fun as cardiology.

From a physiology standpoint, Renee finds congenital heart disease super interesting. It’s like a puzzle where you have to figure out where the blood flows based off of what the anatomy is. So she fell in love with congenital heart disease, to begin with. She also fell in love with the patients. For most kids with heart disease, they’re neurologically intact. So Renee got to bond with each of the patients

Renee would describe pediatric cardiologists as having a unique personality of being able to not only communicate with kids, but also surgical in nature, are cut to the chase, and have high expectations. And she felt she resonated with it as she wants things to be more hardcore.

[05:08] Traits that Lead to Being a Good Pediatric Cardiologist

Renee describes a good pediatric cardiologist as being constantly questioning what is happening and trying to evaluate things in multiple different ways. Try to understand how to use those different modalities to answer a good question. You could order all of those tests on every patient but that would not be good care. So you have to be thinking about what you’re trying to answer and how you can best answer it in a non-invasive way to get the results you need. And if you need to have invasive testing, what is it going to gain, the timing of it. So you need to be able to decipher how you’re going to work a problem up. You have to be able to be collaborative.

In pediatric cardiology, you’re working with surgeons, EP doctors, transplant, heart failure, pulmonary hypertension — there’s a lot of little subspecs when your patient is getting a little bit more complicated. As a pediatric cardiologist, you’re needing to be the conductor in all of this between all of the different specialties when it gets pretty complicated. So be collaborative and be able to deduce how you need to work a patient up and what each test is going to give you.

'Be a calming collective presence for families. Patients who come to see a pediatric cardiologist are petrified, even if it's just an innocent murmur or the kid has chest pain.'Click To Tweet

Moreover, you have to be calm to the patients and their families as parents are walking in the door, worried and freaked out that their kids are going to die. Most of the time, the kids are totally fine. It’s not going to be anything major. But if it is, it’s going to be something they’re going to live with. You’re going to have to be able to dance that wine and speak with parents as you’re trying to give them that information and guide them through it while not totally having them walk out of your office in shambles.

[07:35] Types of Patients

As an outpatient community pediatric cardiologist, she sees a lot of murmurs that are typically benign, like a small hole or small valve defects, nothing major, that typically doesn’t require any procedures or intervention. One of the common ones that present later in life is a large atrial septal defect.

You don’t necessarily pick up murmurs unless there’s a significant blood flow across the hole on top of the heart that it causes some rumbling across the pulmonary valve. A lot of those kids present a little later when you hear that murmur and it can be mistaken a lot for a typical murmur so physicians don’t necessarily send them until later. This would be one of the things that would require some intervention like surgery or cath procedure based off of the defect size.

She also sees chest pain which is rarely ever cardiac. In kids, it’s typically musculoskeletal or lung-related. If it has something to do with exercise, Renee gets those referrals. She also does preventative cardiology, a large portion of her practice is cases with high cholesterol, obesity, pre-diabetes, family history of early coronary artery disease or hypercholesterolemia. She also does a fetal echo. That’s a whole different realm of primary indications that a pregnant woman would need.

[09:45] Diagnosing Patients

The large majority of her patients come to her undiagnosed and then she sees them. She built up the fetal echo practice because of the way pediatric cardiology is today where we rarely pick things up post-natally.

'Because of our imaging abilities now and good prenatal care, we tend to pick up most significant congenital heart defects in utero.'Click To Tweet

If you’re a pediatric cardiologist scanning a patient, they’re doing a fetal echo and identify a defect or a patient needs to deliver, you become that patient’s pediatric cardiologist once they’re born.

Meanwhile, general pediatricians will pick up as an outpatient such as murmur, chest pain, family history, etc. They may do an EKG before they see you but usually, it’s the pediatric cardiologist that does the diagnosing, if anything needs to be diagnosed.

[10:52] Typical Day and Taking Calls

Renee comes in two and a half days a week. She comes in the morning. She basically categorizes her patients. Her heart-healthy lifestyle patients are her more preventative cardiology patients like high cholesterol or obesity patients. It’s more about lifestyle counseling, nutritional, exercise, etc.

For cardiology patients, she will have them get an EKG before they come in. She will review it and walk in the door and decide if they need any further testing. She starts at about 8 am with an hour-long patient slot for new patients. Return patients will have half an hour usually. She sees patients from 8 to 5 on Thursdays and Fridays, doing echoes, and doing EKGs in the clinic room, answering in-basket messages from patients or answering phone calls. Then she’s done by about 5:30 pm after she has closed her charts.

In terms of taking calls, she doesn’t take any in-house calls. She’s actually surrounded by two major universities with very robust surgical and inpatient hospitalization with certain pediatric cardiology patients. So if they need advanced care, they can go to the two children’s hospital near her. She also has some privileges at a couple of local hospitals where she can just get called anytime. And she has the option to take it or not depending on her availability. For her group, she’s on call probably once every 6-8 weeks.

She can just get called by any of the pediatricians in the urgent care or in their clinics, usually reading EKGs or answering questions for them. If there’s anything very dramatic where a kid needs to be evaluated immediately, she can have them go to the hospital she’s privileged at and she can evaluate them there. Or if she knows the children need some advanced care then she could just send them to the children’s hospital.

In terms of work-life balance, Renee considers having great balance. She built her outpatient practice to make sure it’s a 100% possibility, reason that she took the decision to be part-time. That being said, she’s able to balance her outside creative interest, her family, and her own self-care very well.

[14:44] Community vs. Academic Setting

Renee felt she received excellent training in evidence-based, high-quality, very well-thought out pediatric care. Sometimes, when you keep that only in an academic setting, you don’t get to disseminate that kind of care outside. It’s important to bring that kind of care to a community-based setting to be able to provide that same type of care people who wouldn’t be able to travel always to Stanford or UCSF, where they’re located. She thinks this kind of care should be disseminated everywhere. These are the things that led her to be in the community.

'Sometimes, when you keep that only in an academic setting, you don't get to disseminate that kind of care outside.'Click To Tweet

[16:35] Training Path to Become a Pediatric Cardiologist

After undergrad and four years of medical school, you do a pediatric cardiology residency followed by a pediatric cardiology fellowship. There are selective programs now where you can match in a path from medical school, you become a resident for 2-3 years and then automatically go to your cardiology fellowship, you’re guaranteed a spot. But typically, it’s a three-year residency in peds and 3-year fellowship in cardiology, and then a couple of years after that if you want to subspecialize.

There is a hugely growing field in pediatric cardiology called adult congenital heart disease. There are people who do adult medicine first and then spend time rotating through pediatric cardiology to get a better sense of congenital heart disease. They clearly understand the adult onset issues, but they need to understand the pathophysiology and surgical management of the pediatric realm. This is what ends up happening from the adult side and then they treat adult patients more than peds patients. Renee thinks that people who do Med/Peds could do that.

As to competitiveness, Renee describes pediatric cardiology as one of the more competitive specialties of peds. That being said, most people she knew ended up matching into some programs.

To be competitive, a resident has to be hardworking in everything they do regardless of what kind of rotation you do. So work hard and make great connections. Be a good learner and be open to opportunities. People talk to each other so never burn bridges. So working hard is always the right answer.

'Go the extra mile when you're on the pediatric cardiology rotation, but you really should do that across the board because you have no idea who knows who and who could say what about what.'Click To Tweet

[20:55] Special Opportunities for Subspecialization

After cardiology fellowship, other areas for you to subspecialize include electrophysiology or interventional cardiology, pulmonary hypertension. There’s also CVICU, which you can do from PICU or you go and do additional training in cardiology. Or if you’re a cardiology fellow, you can go from cardiology and do additional year in pediatric ICU. Or you can just do an ICU year.

There are also some preventative programs coming up where you can do an additional year of preventative cardiology. And adult congenital disease as mentioned above, which you can do from the peds side. There’s also advanced imaging.

[23:15] Message for the Osteopathic Students

Renee never saw any DO students getting any different treatment or thought process. She believes that if you work really hard, there’s no such thing as luck. Be there, be present. Work hard. Take opportunities where you can. Show off as your best self every time and you can get typically what an MD student would get.

'If you work really hard, opportunities present themselves from the hard work that you do.'Click To Tweet

[24:05] Working with Primary Care, Other Specialties, and Opportunities Outside of Clinical Medicine

'Pediatricians should feel comfortable developing a relationship with a pediatric cardiologist.'Click To Tweet

Congenital heart disease, for instance, is a hard thing to understand unless you do a deep fellowship in it. That being said, feel comfortable calling somebody, even just asking what the pediatric cardiologist thinks. At the end of the day, it’s about having a team-based care.

A lot of what pediatricians see in the clinic would be really taking family history. So anytime you’re seeing a kid complaining about chest pain, really take a detailed family history. And not just cardiac disease but general heart disease, like if anyone in the family has this certain disease or not. Renee advises primary care physicians that if at any time you worry about a heart problem, take a very detailed cardiac family history.

'Lots of things are genetic diseases that are passed down.'Click To Tweet

Other specialties they tend to work the closest with include those from the subspecialized cardiology field, interventionalists, EP doctors, sometimes surgeons, neurologists.

In terms of special opportunities outside of clinical medicine, you can get involved teams doing heart screening. There would be a lot more opportunities in the future as with technology and monitoring.

[28:30] The Most and Least Liked; and Major Changes in the Future

Renee really thinks pediatric cardiology is a very interesting field. What she thinks is cool is that you still get to see the people who you only read about on textbooks.

'It is a super interesting fast-paced, highly evolving field with a lot of really amazingly smart, fun people.'Click To Tweet

What she likes the most about this field is the way she’s connecting with the patients and their parents. They are terrified the moment they walk into the clinic. But she’s able to tell them that they’re going to be totally fine. Of if there is something wrong, Renee is the person who can lead through this whole thing. Being able to take their hand through it all is something humbling. Conversely, what she likes the least is feeling like no matter how much you do, you can never tell with 100% certainty that everything is okay.

In terms of the major changes she sees coming into the future of this field, she mentions the power of the smartwatch where you can pick up certain things.

Ultimately, if she had to do it all over again, she would definitely do it. Her message for medical students and residents is that don’t discount anything along your path. Really check all over again even if you think you’ve found what you really want. Don’t get tunnel-visioned and think like you have to do well it a certain rotation only. Instead, work hard because everybody talks and pediatric cardiology is a super small field and everyone knows everyone. So you’ve got to put on your best face always. Always be showing up with your best self!