When I first became an attending cardiologist, my goal was simple: understand the format of my institution, conform to workplace expectations, and adopt what is colloquially called the "three As" of building a successful medical practice: being available, affable and able.

I now realize that these "three As," popularized over 20 years ago, are no longer a relevant blueprint for success. In the current health care landscape, which has become akin to a hospitality business, getting the job done as a personable and available cardiologist is not enough. Instead, I believe that three additional "As" are now necessary for an early career cardiologist to achieve success: be admired, aware and active.

Be Admired

Nowadays, patients often browse the profiles of many cardiologists and gravitate towards one who appears to provide a higher level of care. Patients may be attracted to a cardiologists' training pedigree, affiliation with an institution or extracurricular endeavors. A distinguishing feature helps an early career cardiologist stand out from the sea of other cardiologists who are competing for the same pool of patients.

Patients have often referenced my resume or my publications as an ice breaker during an initial office visit. Patients with college-bound children like to ask me about Duke University. Snowbirds from the Northeast like to share their experience living in New York City and Boston. While these opening conversations may appear trivial, I recognize the subtle hints of admiration that may have led the patient to choose me as their cardiologist.

Be Aware

In the business of medicine, the clinical work performed by a cardiologist is ultimately measured as productivity, often in relative value units (RVUs). I have met many early career cardiologists who have suffered consequences from or become frustrated by a low productivity evaluation, even though these individuals perceive themselves as being very clinically busy. The solution is often not to work harder, but to work smarter by understanding the nonclinical forces that impair a cardiologists' downstream productivity, which can include institutional politics, biased referral patterns, inadequate clinical documentation, and improper billing and coding.

In my first year as an attending physician, I would routinely track my billing and collection charges, down to the Current Procedural Terminology code. When I detected an issue, I would reach out to the administrative staff overseeing the billing and coding to determine what had gone wrong. Now in my fourth year, I am one of the most productive RVU generators in my practice. By becoming more aware of the nonclinical, and particularly business side, of medicine, I was able to ensure that my clinical productivity translated into financial productivity.

Be Active

As medical trainees, we accepted clinical duties that were explicit and regimented. As early career cardiologists, we should reexamine our assigned attending work roles, realign our clinical interests to address unfilled organizational needs and pursue niches that can grow our practice. We cannot expect those who create our work schedules, including administrators or senior physician leadership, to always know what is best for us.

During the first several years of my early career, I proactively adjusted my work schedule to accommodate evolving practice needs. When I was hired as the third electrophysiologist (EP) in an overstaffed South Miami office, I took the initiative to establish a new EP clinic in Boca Raton, nearly 50 miles away. When I realized that most follow-up office visits were low yield in advancing clinical care, I reassigned those patient encounters as phone call visits. More recently, when one of the EPs in South Miami office practice resigned, I shifted my clinic presence back to South Miami to capture the patient volume created by his absence.

At the end of the day, building a successful practice is tough and requires extensive self-advocacy. We must step outside the confines of only being a clinician and challenge the institutional processes that may be impairing our growth. We should be cardiologists who are not only available, affable and able, but also admired, aware and active.

This article was authored by Edward Chu, MD, FACC, a cardiac electrophysiology specialist at Baptist Health South Miami Hospital in Miami, FL. He is a member of ACC's Early Career, EP and Health Care Innovation Member Sections.