To all practicing general cardiologist- what % of clinical practice includes procedures ?

[Sapien3]

Hello! I am 1st-year CV fellow and intend to be a general cardiologist. I want to get comfortable performing procedures independently. I am just in 2 months into fellowship some of my attendings wouldn't even let me suture during pacemaker insertion. I hope I will get more opportunity in the future. But, we are low volume center and I am not sure how much hands-on experience I would have at the end of my fellowship. As a general cardiologist, when I start my practice I want to be skilled in these. Maybe in future when non-invasive diagnostics take over, TEE and cath procedures may be less performed by general cardiologists. I don't see that happening for pacemakers.

I understand as practicing general cardiologists you can choose to perform or not perform procedures.

THIS Q is for those GENERAL CARDIOLOGISTS who perform procedures -

1) What are the types procedures you perform (TEE, diagnostic cath, or pacemakers)
2) How much percentage does it constitute your clinical practice?
3) What is the impact of it on RVUs?

Thanks in advance

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[nlax30]

As a general cardiologist, at least in your shoes, I would certainly expect to come out able to do TEEs and MAYBE diagnostic caths. Pacemaker implants is becoming less and less common it seems for current general cards and I don't see too many general fellows coming out with that sort of experience unless they happened to train at a program that didn't have a large EP presence.

You are two months in, it's still very early so don't worry too much. I would make it known to your program though that you are interested in these sort of procedures and would like the experience.

 

[cardsguy2017]

What is your opinion based on, especially only 2mo in? What makes you think pacemakers aren't going anywhere but TEE and caths are? Most people only do level 1 EP, to do EP procedures in practice they recommend level 2 which is 6mo of training. The training guidelines and most program's curriculum don't seem to point to a need for pacemaker procedures for gen cards.

From what I've seen, pacemakers are usually done by EP except when it's done by the old-school "general" cardiologists that do a little of everything. If you're in a group, its fine to refer this to the EP person and they may even prefer it. Moreover, it's probably better for the patient, which can be said for a lot of procedures/care. Maybe the only time it may good to be 'well-rounded' is if you're solo but that's rare these days and/or in a rural area.

This is a nice resource on cardiology volumes and data. While they don't mention pacemakers, TEEs are 3x more common than icd's and cath is 11x. Take it for what its worth.

 

[nlax30]

Yea I agree. I see less and less general cardiologists doing device implants in the future, certainly once the current established "old school" guys retire. Same with caths. TEEs will continue to be the main procedure of a general cardiologist.

 

[Sapien3]

This is a nice resource on cardiology volumes and data. While they don't mention pacemakers, TEEs are 3x more common than icd's and cath is 11x. Take it for what its worth.

Great statistics! Thanks for sharing.

Interesting finding
1) PCI to Cath ratio has declined in 2017 - meaning more diagnostic caths which didn't lead to PCI. Hmm.
2) Structural procedures almost increase by 50%
3) TEE % increase is related to a concomitant increase in structural procedures.

I see what you mean- with group practice(most likely my future) pacemakers likely to be done by EP in the group. What about the pacemaker programming? Do general cardiologists do it? I see the trend of calling the EP for that as well, which is saddening. Probably practice pattern

 

[Sapien3]

Yea I agree. I see less and less general cardiologists doing device implants in the future, certainly once the current established "old school" guys retire. Same with caths. TEEs will continue to be the main procedure of a general cardiologist.

One of my attending completely weaned her off cath and pacers implants. She is the boss when she does TEE! Want to be like that.

 

[nlax30]

Great statistics! Thanks for sharing.

Interesting finding
1) PCI to Cath ratio has declined in 2017 - meaning more diagnostic caths which didn't lead to PCI. Hmm.
2) Structural procedures almost increase by 50%
3) TEE % increase is related to a concomitant increase in structural procedures.

I see what you mean- with group practice(most likely my future) pacemakers likely to be done by EP in the group. What about the pacemaker programming? Do general cardiologists do it? I see the trend of calling the EP for that as well, which is saddening. Probably practice pattern

For the most part I think they've given over all managing of devices to EP. I can't really blame them as devices now have gotten pretty complex with each company having some their own algorithm for various functions (minimizing pacing, detecting arrhythmias, etc...) that even for us in EP it is hard to know in details the ins and outs and we deal with these devices every day. The actual implanting of a simple pacemaker is not hard. But as usual the devil is in the details and the problem comes (same for diagnostic cath) when you encounter something beyond just a simple straight forward implant (occluded veins, trouble finding stable threshold at a particular site, etc...), not too mention troubleshoot issues once it's implanted.

Obviously this isn't a problem for most general cardiologist as they stay as busy as they want to dealing with just general cardiology issues. I can certainly see being in a rural area where you have the time and there's the need for you to also manage these other things (diagnostic cath, devices) though most of us don't practice in those areas.