Introduction

So, what brings you to a rotation in cardiology? Are you a third-year medical student fulfilling a subspecialty requirement? Are you a fourth-year medical student excited for the opportunity to pursue your interest and dive into the rotation? Or are you a first- or second-year medical student desperately staring at your computer pondering the feeling of finally ditching your mounds of textbooks and being released into the clinical world? No matter where you are in your medical education, the following information will demonstrate how you can be best prepared for your clinical rotation in cardiology.

Rotation

Cardiology is way more than just cardiology. The field of cardiology contains a wide variety of subspecialties that combine to include acute and chronic management, medical and surgical interventions, and diagnostic and therapeutic modalities. If you have any specific interests (whether it be heart failure, interventional cardiology or something else) make sure you voice those interests to your preceptor before you start or on the first day of your rotation. This will allow enough time to account for any planning that may be required to maximize your rotation experience.

Without further ado, here are the subspecialties you may expect to see on your rotation:

Consult: Think of consults as general cardiology where you can expect a wide variety of clinical scenarios. You will be part of a team that is managing the whole house, meaning you will be first line of the prevention and management of cardiovascular diseases.

What to expect: Expect to see the largest variety of cardiology cases. Just to give you a small taste, here are a few cases I saw on consults: infective endocarditis, abdominal aortic aneurysm, angina, management of comorbidities (hypertension, hyperlipidemia, etc.), valvular diseases and acute coronary syndrome. You will be involved in the different steps of prevention related to cardiovascular disease. Risk strategies are developed through diagnostic tests such as echocardiograms (Echos), electrocardiograms (EKGs) and stress tests.

Heart Failure: These cardiologists are specialists with advanced training in management of advanced or complicated heart failure. You will be exposed to the variety of management options that range from pharmacologic to electrophysiologic and hemodynamic support devices.

What to expect: You will be consulted for help in managing heart failure-related pathologies. Expect to be challenged on the pharmacologic indications for inotropes, chronotropes, diuretics and anti-hypertensives. You will also be at an advantage if you learn the most up-to-date guidelines on the diagnosis and management of advanced heart failure (more on this later). Many of your patients will require management with implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy, ventricular assist devices and heart transplant.

Coronary Care Unit: If your preferred environment falls more into the realm of acute, fast and critical, then you are in the right place. You will be working with an intensive care team to manage various cardiac conditions that require continuous monitoring and treatment such as myocardial infarctions, dysrhythmias, unstable angina and much more.

What to expect: You will be rounding on critically ill patients with adverse cardiac pathologies. You can expect to see many types of bedside procedures being performed. I had the opportunity to see PICC and CVP line placements, axillary Impella catheterizations, intubations and extubations, transesophageal echos, and even a bronchoscopy.

Electrophysiology (EP): These are the electricians of the house. Electrophysiologists study the electrical system of the heart and are experts in the management of cardiac arrhythmias.

What to expect: Your patient base will be narrowed to cases that present with cardiac conduction disturbances. Each morning, I would do inpatient rounds with an attending and a fellow managing cardiac arrhythmias. Sometimes we would get consulted by the emergency department if a patient presented with a life-threatening arrhythmia, like third degree heart block. In the afternoon, I would be in the EP lab spectating diagnostic EP studies and therapeutic procedures such as pacemaker or ICD implants, cardiac ablations, and Watchman procedures.

Interventional: These are the plumbers of the house. Interventional cardiologists use catheter-based treatments targeted towards atherosclerotic coronary arteries.

What to expect: You will spend most of your time in the cardiac catheterization lab, spectating a variety of catheter-based procedures. This field can often be fast paced as many of your cases will be acute presentations referred from the emergency department. You will see different types of structural cardiac procedures such as balloon angioplasties, stenting, atherectomies and percutaneous valve repairs.

Tips

Squiggly lines on grid paper. Oh wait, I mean EKGs. Whether you are a beginner or master at EKGs, understanding the basics behind all those squiggles will help you tremendously. A constant between all the fields within cardiology and even other medical specialties is being able to interpret EKGs. Understanding EKGs will not only allow you to learn more on your own but will also help your preceptors teach you how to become more efficient at interpreting findings. Learning as much about EKGs as you can prior to your rotation is one way you can shine as a medical student because your preceptors will often have a low expectation for you in this area.

Let's get physical. You know I mean physical exam techniques, right? One of the benefits in rotating in a specialty field like cardiology is performing a focused examination. Meaning: you are not expected to do a full head-to-toe physical exam for each patient you encounter, but instead perform an exam focused on findings relevant to the cardiovascular system and of course, your patient. Keep in mind, this does not mean you should neglect all other components of the physical exam that are not cardiology related, but you want to focus primarily on the cardiovascular system while adding other relevant components to each patient. A good rule of thumb is to let your history taking guide which physical exam techniques you will perform on your patient.

Go the extra mile. There are many techniques you can use to help support your differentials for your patient. As a student, we can make ourselves more valuable to the cardiology team (and get valuable practice) by doing more techniques to support the given diagnosis. A good example of this is heart failure: you are assigned to a patient with a history of congestive heart failure who presents with an acute exacerbation. Try to include as many diagnostic findings as you can. Instead of only checking heart sounds, lung auscultation and lower extremities for pitting edema, consider including skin (anasarca, cyanosis, cool and clammy), neck (jugular venous distension), abdomen (ascites, hepatojugular reflex) and so on. It will be beneficial to the patient, your team and yourself if you use each opportunity to practice your physical exam skills.

Lub Dub, Lub Dub. Now, I know a lot of medical students tend to struggle with interpreting heart sounds, or at least I know I did. There is no need to fear. Knowing exactly what you are listening to each time your stethoscope touches a patient's chest is not something that is easily learned outside of the clinical setting. Be patient and understand that most of your learning will stem from your time spent on this rotation. One tip I have for you is do not be shy. If you hear another team member talking about a pathologic heart sound he or she just listened to, use that as an opportunity to ask if you would be able to go and listen. Even if it is not your patient, your team understands that you are a medical student and will be open to letting you auscultate.

Between the lines. That is guidelines, of course. Cardiology is a research-driven field and guidelines for evaluating and treating patients are constantly evolving. You can find a full list of guidelines here. My suggestion to you is to bookmark this page on your phone or device browser so it is easily accessible to you on the wards.

Reflection

My time spent rotating in cardiology was an invaluable experience and I want you to feel that way, too. Always remember to be humanistic and caring for your patients; you can never go wrong if you put your patients first. Take the time to unravel the mysteries behind all your patients. Most of the patients you see in cardiology will carry many comorbidities, and you can use this as a learning experience to connect how different conditions affect one another and how they alter the medical decision-making process. You will constantly face new challenges that force you to step outside of your comfort zone. Embrace these challenges because they will leave a lasting impression on you once you finish your rotation. Use this opportunity wisely. A great way to maximize your experience is to network with attending physicians for letters of recommendation. If you are interested in research, your best chance finding a project is to approach the fellows (or attendings if you do not have fellows at your hospital) and ask if there are any projects or case reports that you can become involved with.

Final Thoughts

Hint of advice to those pursuing a career in cardiology. As we are all aware, the journey to become a cardiologist is a rather longer pursuit consisting of three years of internal medicine residency, followed by three years of cardiology fellowship, and another one to two years if you wish to further pursue a subspecialty track.

With this in mind, I would like to share some helpful advice I received from a mentor regarding the clinical track of becoming a cardiologist. She told me that if you go into internal medicine residency only to become a cardiologist, you will be disadvantaged once you begin your career. Instead, she told me to go into internal medicine residency as if you were becoming an internist. This will allow you to gain the fundamental knowledge and skills to better provide for your patient once you become a cardiologist. I value this perspective. Recall from your preclinical years, the physiology behind cardiology can be influenced by almost any field of medicine. Did the chemotherapy regimen for her breast cancer send my patient into an acute heart failure exacerbation? Do I rush my patient to get PCI or do I just prescribe a proton pump inhibitor? Did the palpitations cause the anxiety or did the anxiety cause the palpitations? Is my patient's hypertension that is resistant to three anti-hypertensives caused by a renal abnormality or maybe an endocrine dysfunction? The list goes on and on, and if we want to become the next best cardiologist, we need to become the next best internist first.