Below are some of my high yield notes for the general cardiology board examination focusing on vascular diseases with easily sharable supplemental articles and tables my reference.
Aortic Aneurysm
Location:
Ascending aorta/root: 60%
Descending aorta: 40%
Both thoracic and abdominal aorta: 5-10%
Surgical Indications for Thoracic Aortic Aneurysm Repair
Patients with infrarenal or juxtarenal AAAs measuring ≥5.5 cm should undergo repair to eliminate the risk of rupture. (Level of Evidence B)
Infrarenal or juxtarenal AAAs measuring 4.0 to 5.4 cm in diameter should be monitored by ultrasound or computed tomographic scans every 6 to 12 months to detect expansion. (Level of Evidence A)
US Screening for Abdominal Aortic Aneurysm
Patient
Level of Evidence
Men 65-75 who have ever smoked
B
Men 65-75 who never smoked
C
Women 65-75 who have ever smoked
I
Women who never smoked
D
*B: high certainty of moderate net benefit *C: selectively offer given moderate certainty of small benefit *D: no net benefit or possible harm I: insufficient evidence
Surveillance Imaging in Known Aortic Aneurysm
Abdominal Aneurysm Size
Frequency
25-29 mm
4 years
30-39 mm
3 years
40-44mm
2 years
*≥45 mm
Yearly
Class IIa, LOE B *Yearly in both thoracic and abdominal aneurysms if ≥45mm. Otherwise repeat thoracic imaging q2-3 years
Risk factors and odds ratio (95% CI): CAD/CVD 2.27, smoker 2, former smoker 1.87, DM1 1.68, HTN 1.47, age 1.39
Clinical Presentation of PAD (i.e. angina of the legs): 50% asymptomatic, 33% atypical limb symptoms, 15% typical intermittent claudication, 2-3% critical limb ischemia
Patients at risk of PAD who should be screened (IIa rec): (1) age ≥65yo, (2) Age 50-64 with risk factors (DM2, smoking history, HLD, HTN) or FH of PAD, and (3) age <50 with DM2 and 1 additional risk factor for atherosclerosis
Location of claudication
Location of disease
Calf
Femoral-popliteal ±aorto-iliac
Buttock & calf
Aorto-iliac
Buttock
Internal iliac
Ankle Brachial Index (ABI)
ABI
Result
>1.4
Non-compressible
1-1.4
Normal
0.91-0.99
Borderline abnormal
≤0.9
Abnormal
*If borderline and good story for claudication: can perform stress ABI (exercise or reactive hyperemia) to augment blood flow through stenosis ** If >1.4: perform toe-brachial index. 20-30% increase is normal. >20 mmHg drop is abnormal
When my co-fellow and started our cardiology fellowship we wish we had an echocardiography reference value cheat sheet. So we decide to make one for our new first year fellows! Our hope is that by having all of the reference values organized in one easily accessible place online that we can ease any new cardiology fellow into their new role. Instead of making it a Word document or PDF we wanted to share it with any other fellows who may find this useful. We will continue to update it with useful educational links, images, and videos over time. *Please only use this as a reference. The most reliable sources of information are ASE guideliens*
Echocardiography Reference Values
Normal Values for Aorta via 2D echo (Indexed to BSA)
Continuous cardiac telemetry monitoring, or ‘tele’ colloquially, is how we remotely monitor patients’ heart rhythms while in the hospital. When it is used appropriately it is a valuable diagnostic tool that assists in diagnosing and managing specific abnormal heart rhythms. I use it everyday for post-myocardial infarction patients (those who just suffered a heart attack) to monitor for ventricular ectopic beats caused by ischemic myocardium (dead heart tissue). Unfortunately tele review is one of those lessons thrown into the hidden curriculum of medical training where people are often taught it on the fly without much guidance. Electrocardiogram, or ECG, interpretation is outside the scope of this post. Instead I will focus on a few helpful tips to help improve your ability to understand and utilize tele in a more meaningful and intentionally manner for any nurse, physician assistant, nurse practitioner, intern, resident, or incoming cardiology fellow. Lastly, don’t forget to subscribe so you don’t miss future posts!
Rule number one in medicine is ‘primum non nocere’ or ‘first do no harm’. Exposing patients to unnecessary monitoring can lead to further unnecessary testing and in turn possible harm. Not only is ordering unnecessary tele potentially harmful to patients but it is also costly. The average hospital bed is more expensive if telemetry is added on. It also can harm healthcare professionals through alarm fatigue. Think about how frequently those things beep along with every other alarm in the hospital. Not to mention how annoying actually wearing a tele monitor can be for patients (1). Inappropriate tele use is such a widespread issue in the United States that it is one of the cornerstones of the Choosing Wisely campaign from the Society of Hospital Medicine (2). Tele should be treated like any other imaging study and only be ordered for specific patients when indicated.
2. Evidence behind tele
No large randomized control trials have established standards of care for cardiac telemetry. However as the old adage goes you don’t need an RCT to prove that a parachute is useful when jumping out of an airplane. There are guidelines established by the AHA/ACC but they are just that- guidelines. In the end, you have to use your clinical judgement when ordering or discontinuing tele. Some of the obvious clinical scenarios when telemetry is useful include
Syncope of unexplained origin (meaning if the patient has obvious vasovagal syncope then you don’t need tele!)
Uncontrolled or unstable arrhythmias (AF RVR, VT)
Following a STEMI
ICU monitoring
3. Common reasons for inappropriate tele use
In residency I attempted to combat inappropriate tele use through a quality improvement project. While partially successful I found that there were a few common diagnoses that accounted for a majority of inappropriate tele use. In the New England Journal of Medicine (NEJM) Journal Watch, Dr. Winawer summarized my thoughts quite well in his post detailing top 10 reasons he has anecdotally seen over his career for inappropriate tele monitoring (5). Remember that these are anecdotes for tele use on the general medicine wards and exclude critical care units. Here are 5 of the most common reasons I see patients inappropriately placed on tele.
1. Abnormal electrolyte derangements. You should not be using tele as a surrogate marker for electrolyte abnormalities. You should be managing the patient with frequent BMP’s. If they have ECG manifestations then they should not be on the general medicine floor and should be in a higher level of care. This include patients with End-Stage Renal Disease (ESRD) with chronically abnormal potassium levels without ECG changes.
2. Low-risk chest pain. If you rule out ACS with negative serial troponin you can DC tele.
3. Non-cardiac syncope. If a patient has a syncopal episode due to hypoglycemia or a seizure then tele has zero utility.
4. Sinus tachycardia. Sometimes patients are admitted for non-cardiac issues and are found to have appropriate sinus tachycardia. This could be due to a fever, pain, anemia, or dehydration. Tele is sometimes used as a surrogate for ‘closer patient monitoring’. If a patient needs to be monitored more closely then they should be upgraded to a higher level of care. Tele is not an adequate replacement.
5. History of atrial fibrillation. If a patient has a history of AF but is rate controlled they do not require tele monitoring. This often happens with patients admitted for something non-cardiac like cellulitis and placed on tele despite being hemodynamically stable.
4. Evaluate the need for tele daily
It is far harder to stop a medication than it is to start one. Same thing is true for tele. So each day that you check your patient’s tele remember to ask yourself if it is even necessary in the first place. This is a responsibility of everyone who interacts with the patient from bedside nurses to the advanced practitioner PA or NP, to both the primary physician and consulting physicians. Everyone has the ability to contribute to more meaningful tele use in the hospital- even our patients!
5. How to look at tele systematically
Okay, okay, okay. I get it. Only order tele when it’s indicated and discontinue it when appropriate to do so. So let’s say we have a patient on tele. Where do we start?
Look at the live feed. See what rhythm your patient is in right now.
Look at events. The computer typically will flag preset rhythms based on an algorithm. It has a high sensitivity so it often flags things that aren’t real arrhythmias. So you have to open each one to evaluate them. When in doubt print out the telemetry strip to have with you to review with your attending physician
Look at the timing of the events. Did your patient have a run of atrial fibrillation last night? Look at the timing of the arrhythmia and ask your patient if they felt it. Similarly if your patient complains of chest pain or palpitations see if there are any events on tele that correlate with that timing.
6. Confirm with an ECG
Tele is great but sometimes it isn’t all that accurate. Always get a confirmatory ECG to compare the rhythm in question.
7. Print out the tele strip in question
I once had a patient who had an abnormal arrhythmia in the ICU. Unfortunately by the time we were able to see the patient they got transferred out of the unit to the floor. When this happened their telemetry data didn’t get transferred with them. So whenever you see something abnormal make sure you print it out and get it uploaded into the patient chart so we can see it in the future. This is also why I like to get an ECG to confirm abnormal rhythms so I make sure it gets uploaded to the EMR.
8. Call for help if you need it
This should go without saying but if you are concerned about a rhythm that doesn’t look right then call for help. If you are an intern and aren’t sure what to make of the tele strip then print them out, discuss with your senior, and on rounds. If you area a nurse then print out the strips and speak to the primary team.
9. But first evaluate the patient clinically
I understand that not everyone is a cardiologist but we are all medical professionals. It is not good enough to simply pass the buck and say ‘I called cardiology about it’. For instance, I’ve gotten calls to say “the patient’s heart rate is 40. What do you want to do?’. Well, it depends! Is the patient fast asleep, hemodynamically stable, and has had normal heart rate trends in sinus rhythm all day? Because a heart rate of 40 could simply be vagal tone brought on by sleep. Or is this a patient who just had a right coronary artery myocardial infarction and is now in complete heart block, feeling dizzy, and becoming hypotensive? My point is that one piece of isolated information is more valuable when put in the context of a clinical situation.
Now let’s go over some real life examples
This is the real meat and potatoes of this blog post. The following case presentations are not based on a single patient and are instead a culmination of many common threads I’ve experienced first hand. So let’s pretend you are a first year cardiology fellow and you are called to evaluate the following patients.
Case Number 1: it’s 3am and you are called because a patient is reported to be in ventricular tachycardia (VT) and the primary team wants to confirm if they should use 100J or 200J for the synchronized cardioversion. They send you a picture of the tele strip, below, while you’re walking to evaluate the patient. What do you tell them to do?
You can tell them to let you and the patient go back to sleep! Here’s why: on the telemetry strip you can see 3 rhythms strips. I labeled them 1, 2, and 3 in red, below. Strip number 1 on the top looks scary. It could be VT! But at first glance it doesn’t look quite right.
Now let’s just jump down to lead number 3 on the bottom. If you saw this lead all on it’s own you would never think “this is VT”. You can see clear cut narrow QRS-complexes. Now go back and look again at the blue circles.
Sinus rhythm with interference
Notice how the narrow QRS-complexes in the bottom lead are also present in the middle lead. Those are pretty easy to march out. The tough part is noticing that they are also present in the top lead. This brings us to our first major learning point. You cannot have an abnormal rhythm in one lead and a normal rhythm in another. If you have VT it should be present in every lead.
So what’s the above diagnosis? It’s tough to make out the underlying rhythm. It could be atrial flutter or just sinus rhythm with prominent T-waves. In the end however it is definitely not VT. The top lead is likely just interference!
Let’s drive this point home and look at another tele strip. Now that you are an expert at figuring out if it’s VT or just interference take a look at this one below.
This is another example where it can easily be mistaken for VT. But look smack dab in the middle at lead III. You can clearly see a regular rhythm with narrow QRS-complexes. You can also see narrow spikes in other leads that correlate with the timing of those sinus beats. The other leads simply have interference.
Now let’s take a look at another tele strip. What’s the rhythm?
In the above tele strip you can clearly see that there are 5 narrow QRS-complexes followed by 7 wide QRS-complexes. This is finally an example of non-sustained ventricular tachycardia (NSVT). In this tele strip the wide QRS-complexes are found in all 3 leads.
Ventricular tachycardia is a wide QRS-complex originating from the ventricle. It is considered non-sustained ventricular tachycardia (NSVT) when it lasts for ≥3 beats but for ≤30 seconds. The 30 second timing is kind of an arbitrary man made classification. But generally if the VT lasts longer than 30 seconds it is classified as sustained-VT. Sustained VT can be deadly because it can deteriorate into ventricular fibrillation (VF) which can be fatal.
To finish out this lesson lets take a look at a 12 lead ECG, below. This is an example of sustained VT.
Diagnosing and differentiating VT from atrial fibrillation with aberrancy is outside the scope of this post but I really like this Life In The Fast Lane blog post on this topic if you’re looking for more information.
Case number 2: you are consulted for ‘runs of sinus tachycardia’. What do you do?
Well first off (*using sassy cardiology fellow attitude*) tell them to try and figure out what the actual rhythm is first and then have them call you back . Okay okay, just kidding..kind of. Let’s dive into why you can’t have a ‘run of sinus tachycardia’.
First off, what should every primary team have done first before calling cardiology about actual sinus tach? The basic work up includes addressing underlying reasons for a patient to be tachycardic. This includes:
Dehydration
Acute anemia
Pain
Fever
Hyper/hypothyroidism
Holding a patient’s beta blocker
Fever tangent: What is Liebermeister’s rule?
Liebermeister’s rule is the appropriate increase in heart rate in response to a fever. In general for every degree abvoe 100F the heart rate should increase by about 10. So a fever of 101 can cause a heart rate of 110. A fever of 102 can cause a heart rate of 120, etc.
Conversely, what is the unusual diagnostic association of fever with bradycardia and what can it indicate? It is known as Faget sign. Faget sign can be seen with intracellular bacterial infections like legionella or mycoplasma pneumoniae as well as many other infections including yellow fever, typhoid fever, tularemia, brucellosis, and Colorado tick fever.
Now let’s say you did all of the above and still can’t figure out wyh on tele you are seeing runs of a fast heart rate. Sometimes looking at the graphic trend can help differentiate different rhythms.
First just think about what your normal heart rate does while in sinus rhythm. Throughout the day if you get up and move around your heart rate increases gradually to accommodate for increased cardiac output requirements. Think about when you walk up a flight of stairs or two. Your heart rate increases slowly. It doesn’t suddenly jump from 60 beats per minute to 150. It slowly climbs up to 65, then 70, then 75, then 80 and so on. Then in recovery after you finish climbing the stairs your heart rate similarly will slowly trend down and decrease slowly from 150 to 145 to 140 and so on. Below is an example of a patient who is in normal sinus rhythm without any arrhythmias.
The above graphic trend is for a 24-hour period. So the small spikes that you see are actually happening over a longer period of time. If we were to zoom in you would see a gradual upslope and then gradual down slope.
Now don’t get fooled. This can also happen in atrial fibrillation. Patient’s can be rate controlled pretty well and have gradual increases in their graphic trends. So just because the graphic trend is gradual it does not mean that it is sinus rhythm. Don’t forget the rules of telemetry. Get an ECG or check the rhythm yourself to figure out what you are dealing with.
Now our patient in question was having ‘runs’ of tachycardia, as seen below.
Above is the graphic trend over an 8hour period. These bursts of fast heart rhythms are starting SUDDENLY and stopping SUDDENLY. This should not happen in sinus rhythm and indicates that you are likely dealing with some type of abnormal heart rhythm. Arrhythmias that can commonly do this include atrial flutter, atrial fibrillation, and atrial tachycardia.
The learning point here is that the graphic trend can be used to help guide your diagnosis. You cannot solely rely on the graphic trend to make a final diagnosis. You still have to go inside the event strip and FD, or full disclosure, strip in order to figure out what rhythm you are dealing with. When in doubt, print it out! And then call your friendly neighborhood cardiology fellow for some help to figure it out together.
Overnight I got called again abotu this patient’s heart rhythm. The primary team thought it was an SVT so they used adenosine to break the rhythm. Below is what they saw (sorry for blurry image).
In the above image the patient was going in a fast rhythm and adenosine was administered. Adenosine slows AV-nodal conduction. So all that it does it stops the atria from communicating with the ventricle. It does not necessarily stop whatever rhythm is happening inside the atria. In the above strip you can see that after the 5th narrow QRS-complex there is long pause until the next QRS-complex comes in. During that extended time period you can still see about 8 P-waves. This is highly suggestive of atrial tachycardia and is the first thing that comes to my mind when a patient is having ‘runs of sinus tachycardia’.
Atrial tachycardia can look like sinus rhythm, suddenly start, and suddenly stop. Again the full treatment of atrial tachycardia is outside the scope of this blog post but if you want to read more about it I like this LITFL blog post on atrial tachycardia.
Lastly, let’s take a look at another graphic trend, below.
Notice how this rhythm also suddenly goes fast and then suddenly goes slower. This is indicative of an underlying arrhythmia. I would be impressed if someone called me with a consult with this information at hand for assistance in rhythm identification. This is some ‘upper level senior resident who is interested in cardiology’ level of knowledge!
Again, graphic trends can be a valuable tool to help guide your ECG diagnosis but always get a 12 lead to confirm! And if rhythms and ECG’s are still tough for you then don’t worry because I still get them wrong at times. Medicine requires lifelong learning so use every one of your patient’s ECG’s as practice!
If you think this blog post helped then comment below and I hope be sure to subscribe so you don’t miss the next blog post!
Henriques-Forsythe MN, Ivonye CC Jamched U, Kamuguisha LKK, Onwuanyi AE. Is telemetry overused? Is it as helpful as thought? Cleve Clin J Med [Internet]. 2009 Jun [cited 2012 Sep 4];368-372.
SHM – Avoid continuous telemetry monitoring | Choosing Wisely. (2020). Choosingwisely.org. Retrieved 22 May 2020, from https://www.choosingwisely.org/clinician-lists/society-hospital-medicine-adult-continuous-telemetry-monitoring-outside-icu/
When Should Hospitalists Order Continuous Cardiac Monitoring?. (2020). The-hospitalist.org. Retrieved 22 May 2020, from https://www.the-hospitalist.org/hospitalist/article/122074/when-should-hospitalists-order-continuous-cardiac-monitoring
NEJM Journal Watch: Summaries of and commentary on original medical and scientific articles from key medical journals. (2020). Jwatch.org. Retrieved 23 May 2020, from https://www.jwatch.org/na44560/2017/07/06/dos-and-donts-telemetry-monitoring-telemetry-directors-top
Given existing disparities in access to health care the growing burden of heart failure in the US could disproportionately impact the African-American and minority community (1).
Regardless of race or ethnicity, patients with heart failure (HF) have better outcomes when cared for by cardiology specialists than other specialties (e.g. internal medicine) (2,3).
However, prior studies on patients admitted for decompensated heart failure found those with lower incomes or patients who were AA were ‘significantly less likely to receive cardiology care when compared with younger, Caucasian, and more educated patients. Even after adjusting for severity of illness, social factors were strongly associated with receiving care from a cardiologist’ (4).
In a larger database study published in 2018 of over 100k patients including over 20k AAs the authors found that Caucasians were 40% more likely to receive cardiology care than AAs(5).
As an editorial commented ‘can we continue to blame the disparity in care to lack of access or insurability? Is it not time to consider preconceived notions of access and inherent, although unrecognized, racial bias and stereotyping that lead to racial health disparities?’ (5).
I won’t pretend to be an expert in racial issues or healthcare policy but it is evident that generations of racial and socioeconomic disparities manifest in poor health and that we must recognize and challenge our own bias both personally and professionally.
Piña, I. (2018). If It Is Not Health Care Access or Insurance Coverage, Then Why Do Racial Disparities Persist?. JACC: Heart Failure, 6(5), 421-423. doi: 10.1016/j.jchf.2018.03.013
Uthamalingam S., Kandala J., Selvaraj V., et al. (2015) Outcomes of patients with acute decompensated heart failure managed by cardiologists versus noncardiologists. Am J Cardiol 115:466–471.Google Scholar
Selim A.M., Mazurek J.A., Iqbal M., Wang D., Negassa A., Zolty R. (2015) Mortality and readmission rates in patients hospitalized for acute decompensated heart failure: a comparison between cardiology and general-medicine service outcomes in an underserved population. Clin Cardiol 38:131–138.Google Scholar
Auerbach A.D., Hamel M.B., Califf R.M., et al. (2000) Patient characteristics associated with care by a cardiologist among adults hospitalized with severe congestive heart failure. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Coll Cardiol 36:2119–2125.FREE Full TextGoogle Scholar
Breathett K., Liu W.G., Allen L.A., et al. (2018) African Americans are less likely to receive care by a cardiologist during an intensive care unit admission for heart failure. J Am Coll Cardiol HF 6:413–420.Google Scholar
As a general cardiology fellow I discuss the risks and benefits of medications, diagnostic tests, and procedures with my patients everyday. Often I’m asked about unproven herbal remedies or over the counter (OTC) supplements. So let’s use a popular supplement used for cardiovascular disease to talk about supplements.
Supplements and the Food and Drug Administration (FDA)
The issue with these over the counter supplements is that they are not regulated by the FDA. When a drug is FDA approved it means it has generally gone through extensive testing to understand its safety and efficacy for specific indications. Drugs that are not proven to be efficacious or safe are not approved. FDA regulated medications also have quality control measures. It means that drug companies are required to prove that the drug you are taking is in fact of high quality and purity- that what you are prescribed is what you are actually taking. Conversely, non-FDA regulated supplements are not held to the same rigorous standards.
Here’s an example- red rice yeast
One example from the field of cardiology is the supplement known as red rice yeast. It is sold as a cholesterol lowering medication and as an alternative to prescription cholesterol lowering drugs. Red rice yeast contains monacolin K and is the active ingredient found in lovastatin that helps lower cholesterol levels. So it can in fact actually lower your cholesterol levels. However the quality and purity of the supplement is not nearly the same as that found in its prescription counterpart.
In 2017 a study from the European Journal of Preventative Cardiology researchers analyzed 28 brands of red yeast rice supplements to quantify their monacolin K content, the active cholesterol lower ingredient. To no surprise the authors found that ‘the strength and composition of red years rice supplements sold at mainstream retail stores in the United States remains unpredictable’ (1). In 2 brands no monacolin K was detected at all! In the 26 other brands the quantity of the active ingredient ranged from 0.09 to 5.48mg per 1200mg of red yeast rice. That’s a 60-fold range in quantity. Imagine being prescribed a medication and not knowing if you were getting 0.5mg or 5mg. Additionally if patients followed the manufacturers’ daily serving recommendations they could consume a range of monacolin K from 0.09 to 10.94mg- more than a 120-fold range in dosage (1). In summary, you don’t know how much of the medication you would actually be taking. Not only does this raise the question of the efficacy of the supplement but also its safety.
So should you be taking supplements at all?
Generally, if you are eating a well balanced diet you should not need to be taking supplements. A colorful diet rich in fruits and vegetables is the best natural supplement that you can take. For more information on healthy dietary choices and plant based diets check out two great handouts below created by cardiology fellow Dr. Danielle Belardo who hosts a nutrition podcast, blog, and cardiology clinic on plant based diets.
Okay but is it unsafe or unhealthy to use supplements?
At the end of the day the first thing you should do before you take any supplement is talk to your doctor. From a doctor’s perspective, we want to make sure that any supplement you take does not interact with medications you are currently taking and ensure that any supplement in question does not have serious side effects.
Conclusion
There are no magic pills. I’m always amazed that we know the most about the human body today than we ever did in human history but there still are no magic pills. As far as the medical field has come we still can’t cure every disease, ache, or ailment. Be extremely cautious about anyone selling a product with claims that sound too good to be true because they often are just that- not true. Supplements are a multibillion dollar industry and the last thing I would want to happen is for a patient not to be able to afford proven life prolonging medications because they were buying unproven and potentially dangerous or impure supplements.
Works Cited
Cohen, P. A., Avula, B., & Khan, I. A. (2017). Variability in strength of red yeast rice supplements purchased from mainstream retailers. European Journal of Preventive Cardiology, 24(13), 1431–1434. https://doi.org/10.1177/2047487317715714
In June I completed my three year internal medicine residency at Hahnemann University Hospital/Drexel University College of Medicine. In July the hospital, recently sold to new owners, shut its doors.
I wasn’t impacted directly. However active residents and fellows, including first year residents starting the first month of training who moved their lives and families, were forced to find new residency programs. Our program leadership were incredibly supportive and helped these residents and fellows find new hospitals to finish their training. We thought it was in the rear view. It was stressful but it was over. We got out. Turns out that was just chapter one.
Last week our Program Director (PD) informed us that the current owners of the hospital would likely not be covering our tail end medical malpractice insurance. It will likely cost a few hundred to a few thousand dollars depending on the duration of malpractice needed. It can be much more expensive for other fields like OB/GYN or emergency medicine. You can see the full email sent from our PD in my tweet below.
Email from our Program Director detailing ex #Hahnemann residents will need to purchase tail end malpractice insurance pic.twitter.com/EytSAf2spz
You might be wondering how this is legal given it is detailed in our contract that they have to cover tail end malpractice insurance. Well, it isn’t but they’re doing it anyway. You also might be wondering what tail end medical malpractice insurance is and until a week ago I didn’t know either as I detailed in my Instagram post below.
I spoke with Whyy Philadelphia who went into further detail in the article below. They were also able to speak with Dr. Aizenberg, Hahnemann’s venerable former Internal medicine program director.
Former Hahnemann residents and fellows impacted by this are organizing. In the meantime, we await a final ruling to decide our fate. Unfortunately as Dr. Aizenberg outlined in his email it doesn’t look like the situation will result in a favorable ruling for former Hahnemann residents. Even if a decision is made to have our former employer follow through with their obligations outlined in our contracts it won’t happen for quite some time down the line. This leaves residents to foot the bill. Yet another out of pocket expense that many can’t afford and further stress on an already heavily burdened group of doctors in training.
A broken healthcare system failed the patients of Philadelphia and now continue to fail it’s doctors. One of my favorite social media doctors, ZDoggMD spoke about Hahnemann in one of his most recent video posts, below.
ZDoggMD on continued Hahnemann closure issues
Many people have pointed for assistance or guidance from medical residency training oversight boards like the ACGME. Unfortunately this likely won’t be a quick fix with a linear projection. At this time we have not been told of any further developing communication from them or any other medical boards.
Ultimately I’m thankful that I got lucky. I was on vacation during the last week of residency when I found out Hahnemann was closing it’s doors. This is the first time I’m directly impacted by its closure. For many of my colleagues from Hahnemann however this is yet another impediment to their future.
Current third year residents need to find jobs and can be uniquely impacted by this issue. You need tail end malpractice insurance to work. I am no expert in malpractice or physician contracts but I’m told that some hospitals simply won’t hire you if you don’t have it. They’re going to be forced to buy it. Others are seeking fellowship positions and this issue will certainly carry on with them wherever they match. I hope that fellowship programs view ex-Hahnemann residents like I do- with respect and admiration for not just persevering through these challenges but thriving despite them.
Some of my prior colleagues and I didn’t always see eye-to-eye. It happens when you have, shall we say, a ‘strong personality’. But to my ex-Hahnemann colleagues I promise to continue to advocate for you and use my platform to spread awareness of this developing situation. We share a common bond and unfortunately we are the last group of residents that will ever know the meaning and depth behind the phrase ‘welcome to Hahnemann’.
People wonder why the medical field is going through an epidemic of professional burnout. This developing story embodies the issue. We are viewed as expendable and nothing more than part of the bottom line and treated like it. Not all hospital systems run like this and I hope that this will become an exception to the rule but only time will tell.
So what can you do to help? Share this story. First comes awareness. Next comes action.
I just started a new YouTube channel! My first three videos are on Caribbean med schools, why I chose to pursue an internal medicine residency, and how to get a cardiology fellowship and become a cardiologist in the US. Watch them below and be sure to subscribe! The next videos coming out will be patient centered about heart health!
I’m excited to share my next interview. Keerthi Shah was a senior resident at my residency program and is now a first year gastroenterology fellow at Hahnemann University Hospital/Drexel University College of Medicine.
Thanks for letting me pick your brain Keerthi. Can you tell my followers a little bit about yourself?
I would love to! I’m a PGY-4 or a first year Gastroenterology (GI) Fellow at Drexel University College of Medicine.
I grew up in Georgia most of my life. I went to Georgia Technology for undergrad and then Philadelphia College of Osteopathic Medicine for medical school (the GA campus). When I’m not practicing medicine I love to dance and travel. I’ve been learning, teaching and performing kuchipudi, an indian artform, since I was 7!
I’ll start off with another softball question and take you back to your residency days. Why did you go into medicine?
I was always pretty sure that I wanted to do medicine and then specialize. Combining patient histories with objective data to figure out the diagnosis was like a puzzle. I liked that kind of challenge. In addition, having such a broad knowledge base prepares you for any future fellowship.
Did you always know that you wanted to go into GI?
No! I was between nephrology and gastroenterology when I started residency. These two fields are worlds apart!
The biggest reason I found my way to GI is the procedures. There is such a satisfying feeling about working with your hands and learning a new technical skill. Even during my time in medicine, I enjoyed placing central lines and performing paracentesis. I knew the learning curve would be very steep, but I was ready for that challenge!
To be extra sure of this path I spent months exploring gastroenterology and hepatology, both inpatient and outpatient. All this time just made me more sure and excited.
GI fellowship is three years. What are the subspecialties in GI and how long are they?
There are 5 main subspecialities in GI: (1) motility and functional GI disease, (2) Inflammatory Bowel Disease, (3) advanced endoscopy, (4) nutrition/obesity and (5) hepatology/transplant hepatology. You can choose to do an extra year or you can attend symposia and workshops to build those skills. You essentially don’t have to do the extra year to be able to practice most of those subspecialities. The only exception is advanced endoscopy and trnsplant hepatology which is 2 years and 1 year respectively.
Do you think you will stay as a general gastroenterologist or do you plan on pursuing a subspecialty?
I’m fortunate to be at a program that exposes fellows to subspecialities. Honestly, I’m just enjoying learning about every area of GI. Motility, nutrition, and IBD are areas of focus that I’ve particularly enjoyed. For right now though, I plan to stay general gastroenterology.
I remember you telling me about a pretty alarming turn of events during interview season that almost left you without a fellowship. What happened and what lesson should fellowship applicants take away from it?
I’ll start out saying I’m an osteopathic physician. When I was applying, I applied to both MD and DO programs. Some of the DO programs are still outside of the match process. I interviewed and got accepted at one program. After a lot of thought, I accepted the position and cancelled the rest of my interviews. A couple days before the match, the program contacted me saying they could no longer give me the position because of internal issues. I scrambled to get interviews back. Luckily everything worked out and I matched at my home program. Needless to say, this was a stressful couple of days! The moral of the story is to not cancel anything till the contract is signed.
Gastroenterology is one of the most competitive internal medicine fellowships. What are the most important aspects of a GI fellowship application?
Great letters of recommendation, which stems from good mentorship, are the most important part of your fellowship application. Take the time to get to know the GI attendings at your home program. Work in the inpatient and outpatient clinics.. Get letters from these physicians! Their names are known in the GI community and getting a great recommendation will go a long way.
Research is a must for competitive fellowships like gastroenterology; however quality is valued over quantity. Programs like to see that you took a project to completion from conception to poster/oral presentations and eventually to publication.
Lastly, work hard! People will notice your hustle and that will make your LOR’s even better.
What research did you do during residency?
My first project was assessing quality of life (QOL) in transplant recipients and the use of group experiences to improve QOL. I was fortunate to be able to present this at an international conference and very recently published in Pediatric Transplantation Journal.
I did mostly hepatology research because my first mentor at Drexel was Dr. Santiago Munoz. The two notable projects were addressing etiology and prevention of hyponatremia in cirrhosis at an inner city hospital and expanding inclusion criteria for Obeticholic Acid in Primary Biliary Cirrhosis. Both projects were presented at GI conferences.
From there I expanded to gastroenterology. I worked with our Motility focused attending on evaluating Dysynergic Defecation with 3D High Resolution Anorectal Manometry.
Did you do any quality improvement projects?
I did one quality improvement project analyzing and improving night float and nursing communication using cell phones and text paging. The current pager system is such an archaic interface for communication. Our hospital is now transitioning to a phone based night float system.
What general advice do you have for prospective residents who want to pursue gastroenterology?
Spend time getting to know the GI program at your hospital. Work with them inpatient and outpatient. Do research with them.
The hardest part of fellowship is the volume of consults and learning a new technical skill. Hard work and a good attitude will go a long way.
You recently started a blog. Tell me about it. What’s your vision for your blog?
I recently started this blog initially to answer questions from my friends and family. I wanted to be able to provide them with answers that were based on up to date literature.
Our interactions with patients in the clinic are so brief. In 15 minutes, we are expected to take a history, diagnose, and treat. This leaves patients’ with a lot of questions and they seek their answers on social media. I wanted to be a part of the social media dialogue. I also wanted this to be my way of supplementing abbreviated clinic time to explain gastroenterology topics to patients in an effective way.
Where can my followers find you on Instagram? What can the expect to see?
In a nutshell, my Instagram is a combination of 3 things: GI, travel and friends/family. When it comes to gastroenterology I hope to perpetuate evidence based information as well as tips and tricks for aspiring GI fellows.
What’s the weirdest question people ask you after they find out you’re a GI fellow?
Honestly nothing weird! People ask me a lot of questions regarding their bowel movements. I think the strangest part of being a fellow is the number of pictures of stool I have on my phone.
How much poop is too much poop?
Well, everyone’s “normal” is different! Too much poop for you might be someone’s normal! The number of times you go isn’t as important as the consistency of your bowel movements. If you’re having 3 or more loose/watery Bristol 5-6 bowel movements, we need to talk!
Why do you get the day after drinking diarrhea?
Acute alcohol consumption inhibits absorption of nutrients and fluids. this stimulates secretion of water and electrolytes. effect of alcohol on CNS increases colonic motility and transit time. This prevents absorption of water in the large intestine. If you are drinking sugary mixed drinks, you might be drinking sugar substitutes, which causes osmotic diarrhea.
A patient recently asked me about constipation. What are some common home remedies patients can try?
Constipation affects so many people and results in many hospital admissions. Some things people can do at home include exercise, fiber supplementation, answer nature’s call, and improve your stooling posture. Osteopathic Manipulative Medicine (OMM) can also be helpful. Check out my blog post for more details!
Thank you so much for sharing some insight into the world of gastroenterology Keerthi. As always be sure to subscribe below so you don’t miss out on the next post!
Joel Alcid is a third year internal medicine resident finishing up his final year of residency at Hahnemann University Hospital/Drexel University College of Medicine. Next year he will be starting his fellowship training in hematology and oncology. I sat down with him to learn more about how he earned this monumental achievement and tips for medical students and residents who are interested in pursuing a heme/onc fellowship too
Thanks for letting me pick your brain Joel. Can you tell my followers a little bit about yourself?
Thank you for this opportunity. I am happy to share my thoughts and provide some guidance for those who are interested in pursuing a career in hematology/oncology. But first here are some fun facts about me
I am Filipino-American
Born and raised in North Jersey
Attended the University of Hartford and majored in respiratory therapy (yes, I originally thought of pulmonary/critical care prior to med school)
Attended the American University of Antigua for medical school
I’m a huge boxing fan, my favorite boxer is of course…Manny Pacquiao
I currently train at James Shuler’s Gym in West PhillyI recently got married in August of this year in Riviera Maya, Mexico
Did you always know you wanted to pursue hematology and oncology (heme/onc) fellowship? What about it attracted you?Yes. I knew since my third year of medical school that I wanted to pursue a career in hematology/oncology. I was always interested in the variety of pathology within the field, especially the cancer aspect. During my fourth year of medical school I was fortunate enough to do a one-on-one sub-internship rotation with an attending in his private practice. I had the chance to gain firsthand experience of what a career in heme/onc would be like. The diversity and complexity of the cases I was seeing on a daily basis attracted me to this specialty. From a patient with recurrent invasive ductal carcinoma who had developed metastasis to bone to a patient with a skin lesion that was diagnosed as mantle cell lymphoma.
Another aspect of the field that I developed immense respect towards during my rotation was the chance to support patients through their emotional struggles. Close patient contact and forming relationships with the patients is an important aspect of medicine in which I really enjoy and I feel the doctor-patient relationship seems especially important when the battle against cancer is shared over many years and often through multiple phases of progression and response. It’s definitely an exciting time to go into heme/onc as there are many new up and coming treatments along with endless ongoing clinical trials.
Do a lot of subspecialties in heme/onc exist? Are they traditionally additional years of dedicated fellowship training?
Great question. Those who are pursuing a career in academics tend to specialize in one area of hematology or oncology such as only treating breast or lung cancer for example. Most academic centers have faculty members for each type of cancer. Just like internal medicine, it is difficult to “know everything” and I think that’s why some are heading into the direction of just focusing on one type of cancer. A sub-specialist in an academic setting will generally spend most of their time geared towards research, clinical trials, teaching and maybe 1 or 2 days of clinic. How it typically works is you would either tailor your practice towards your specific interest or look for an opening in your area of interest which will usually be in an academic center.
For those who want to pursue a career in bone marrow transplant, additional fellowship training is required. Bone marrow transplant is an advanced fellowship which is an additional year after completing the initial 3 years of heme/onc. There are some non ACGME accredited 1 year fellowships available at top cancer centers like MD Anderson for leukemia, lymphoma, and myeloma.
Do you plan on pursuing a subspecialty?
Although I have an interest in solid tumors I will not be pursuing any subspecialty. The variety of pathology is what attracted me to this field so I would like to be a “generalist” and treat all types of cancer. If I only focused on breast or lung for example I would definitely miss seeing patients with myeloma, pancreatic, prostate, or even gynecologic cancers. My career goal is to go into private group practice and treat a variety of malignancies.
Every specialty is becoming more and more competitive to match into. Can you share with us some data on what your fellowship application looked like?
I definitely agree that most specialties continue to become more competitive each year. Here are some data for hem/onc from the 2018 NRMP fellowship match data
553 spots with 760 total applicants
73 % matched, 27% went unmatched
US allopathic grads: 327 matched, 62 unmatched
US IMG’s (like Caribbean med grads): 36 matched, 48 unmatched
Non US IMGs: 142 matched, 95 unmatched
Osteopathic: 34 matched, 15 unmatched
Below are the details on the statistics from the NRMP match data. You can see the average USMLE step scores for matched and unmatched applicants from US medical schools, IMG’s, international medical graduates, and osteopathic graduates. For instance, the average USMLE step 1 score of US, IMG, and international matched grads respectively were 239, 237, and 242.
What research did you work on during residency? Was that below, above, or an average amount of research for someone applying to heme/onc?
Research is a major component of the fellowship application (especially compared to residency). Research can be any abstracts, poster presentations, publications, or quality improvement projects. Anytime I would see a patient with a rare malignancy I would look it up to see if there have been any case reports published and if only a few have been reported, then I would use that opportunity to write up my own case report. I was taking care of a patient with a primary DLBCL (diffuse large B-cell lymphoma) of the cervix and primary pulmonary angiosarcoma (both extremely rare) and took the opportunity to write them up. They were both accepted for publication in an online oncology journal and have been presented as poster presentations at several meetings. I also worked on a case series with a gynecologic oncologist comparing patients with low grade serous ovarian cancer that was also published in an online oncology journal.
As far as poster presentations, I was able to present some of my abstracts at several meetings including the Lymphoma and Myeloma International meeting in NYC, the American College of Physicians Southeastern PA chapter meeting, the Drexel Discovery Research Day and our departments own internal medicine annual research day. I also presented an overview of the treatment guidelines for autoimmune hemolytic anemia at the Drexel Hematology journal club.
Here are some data regarding research from the 2018 NRMP fellowship match. For US allopathic grads, the average research (abstracts, presentations and publications) was 9.1 for matched and 8 for unmatched. US IMGs had 12.5 for matched and 4.5 for unmatched. Non US IMG had 16.5 matched and 9.6 unmatched. Based on this data, the more research you have, the safer you are to match. Bottom line..find time for research!!
Did you complete any quality improvement projects?
I worked on a quality improvement project with 3 other residents who were also going into heme/onc. We decided to evaluate blood transfusion utilization and cost analysis at Hahnemann University Hospital. We conducted a retrospective chart review of packed red blood cell transfusions administered at Hahnemann University Hospital during the month of May 2017. Data collected included pre-transfusion hemoglobin level, quantity of units transfused, post-transfusion hemoglobin level, the patient’s primary service, and level of care. One hundred and fifty-three charts were reviewed across all specialties and units. Twenty-one percent of blood transfusions in this period, representing 41 units of packed RBC, were determined to be inappropriately administered. Based on the figures from the ASH 2008 study, the estimated patient costs of these inappropriately administered units may be as high as $140,753. Our conclusion was that the number of blood transfusions administered during the period under review that did not follow the AABB guidelines was substantial. Stricter adherence to established evidence-based guidelines for red blood cell transfusions could represent a significant cost-saving measure.
What advice do you have for medical students interested in pursuing heme/onc?
For medical students who know they want to pursue hem/onc…more power to you! To make yourself a competitive applicant for residency, you must do well on USMLE step 1 and step 2 CK. Lower than average scores can hurt you in the long run and yes they still matter for fellowship. I would recommend setting up 1 or 2 heme/onc electives during your 4th year so you can get an idea of what it’s like to be an oncologist. Try to rotate at the outpatient clinic, as heme/onc is primarily an outpatient specialty. An inpatient or consult elective would be a misrepresentation of what the specialty is truly like.
When rotating on a hem/onc elective try to attend all of the conferences such as tumor boards and ask if you can even present a case. Feel free to ask the fellows and attendings questions on what their daily routine is like. Remember, to become a hematologist/oncologist, you must first get accepted into an internal medicine residency. So work hard and ace those boards!
What advice do you have for residents who are interested in pursuing heme/onc?
For residents interested in pursuing heme/onc, I would make sure the attendings and fellows know you’re interested from the beginning. Try to do as many rotations as you can whether it be the inpatient service, consults or outpatient clinic. The more they see you around, the more they will see that you are truly interested. I know not all residency programs will have an in-house fellowship or not have any available heme/onc rotations so I recommend scheduling an away rotation at program that has a heme/onc fellowship. This can be an “audition rotation” and might be beneficial in the long run (letters, connections, etc).
Also try to join any heme/onc interest groups and if there are none then perhaps create one! This will definitely look good on the CV.
As mentioned above, research is a vital component of the fellowship application. Try to get started early (as early as first half of intern year). Some projects will take time and you want to make sure you have enough to put on your CV come application time (towards the end of PGY-2). Ask around if any ongoing projects are available for you to join. Senior residents and fellows are good resources to ask.
Ask for letters in advance (anywhere from January-April) depending on the size of the residency program. Internal medicine program directors have to write a letter for every resident applying for fellowship so make sure to notify them early so they have ample amount of time.
How many programs did you apply to, interview at, and rank?
Hem/onc gets more competitive every year. I thought I had a decent application (also reviewed by current fellows and attendings) but I was surprised with the response I received from programs. I applied broadly to around 80 programs and only received 6 interview invites. I ranked all 6 programs and I’m thankful that I matched. I heard the safe number of interviews to have to increase your chance of matching is around 6-10 but that is variable. Some have matched with fewer and some didn’t match with 10 or even more.
I will training at East Carolina University/Vidant Medical Center in Greenville, NC. I am definitely excited for this opportunity but will miss my family and friends in Philadelphia/New Jersey.
If you had to be a component of plasma what would you be?
Hmm…I would probably be the globulins..since they are important for immune system and help protect against bacteria and viruses. I can put the boxing training to use!
If any of my readers have a follow up question where can they find you?
My instagram is @joelal_md and my email is [email protected] . Please feel free to contact me with any questions
One of the most frequently asked questions that I receive from medical students is about how to prepare for their first year of resident. It parallels one of the most common fears among medical students in that they will not be adequately prepared for day one of residency. It’s a valid concern because you will never truly be ready for intern year but if you’ve made it this far in your training then you are likely ready enough. Almost everything you learn intern year isn’t taught in medical school because you have to do actively do it to learn it. At least that’s what I thought until I came across OnlineMedEd.. It’s the only resource I’ve found that actually prepares medical students reasonably well for intern year. Again, nothing is going to make you fully prepared but this is as close as you’re gonna get.
I started using OnlineMedEd during third year of medical school
OnlineMedEd is an amazing resource with videos that help explain complicated topics that overlap real world experience with the textbook. They do an amazing job of translating all of that USMLE step 1 material into actual practical knowledge so you can look sharp on all of your third year rotations. I would watch a few before each rotation started and it showed. Dustin and the OnlineMedEd team also drill home all of the important facts that are frequently tested on step 2 CK. Sure, nothing will ever replace UWorld but OnlineMedEd gives it a run for it’s money. Start using OME early and often.
A curriculum for fourth year medical students
Your fourth year of medical school is a magical time especially after interview season is over and your rank list is finalized. You’re basically just waiting to graduate and planning your vacation to South East Asia. It is all to easy to fall into a trap of laziness and forget that you are going to be a full fledged doctor in 6 short months (well technically you’ll be an intern but a doctor nonetheless). If you dedicate yourself to the structure of OnlineMedEd during your fourth year you will have a dedicated curriculum that keeps you fresh and sharp on the wards. Sure, you’re still gonna forget a lot before intern year starts but at least OnlineMedEd will get you into some good habits.
It prepares you for intern year
My advise to all of my fourth year medical student is always the same- go home because life is too short to be spent in the hospital watching me type notes and at least one of us should see the sun today. I also tell them that the best way to be a good intern is to develop good habits while you are still in medical school. The dirty truth about residency is that you don’t need to be all that intelligent to be a good intern. You simply need to be efficient, thorough, and work hard. The sooner you develop habits that enable you to work smarter, and not harder, the better off you will be. OnlineMedEd has developed a fantastic Intern Boot Camp that helps you do exactly that. If I could do my fourth year all over again I would use the Intern Boot Camp and test out what does and does not work for me while I was still on the wards in the hospital. That way when I show up day one of residency I at least had a system that I knew worked for me. It’s like when I had to learn how to actually study in medical school- I wish I didn’t have to go through the process of figuring out what works best for me. I wish I knew how to study more efficiently back in undergrad. Likewise, take the time to learn the ropes of what it takes to be an intern while you are still a medical student.
Start studying for step 3
Ugh I know. Sorry for bringing up the USMLE’s again but you have to get it over with eventually. I’ve written extensively about when you should take USMLE Step 3 as well as how to study for USMLE step 3.If you use OnlineMedEd during your fourth year of medical school you will get a head start on it. You don’t need to use OnlineMedEd as your primary study aid but it will certainly help cement concepts in your head and make it easier for you once you start your dedicated step 3 study period as you transition from medical student to resident.
They also have great study products
Last thing I’ll mention are their study aides. The Intern Guide Book and the Quick Tables Book are great study tools for medical students. They succinctly provide you with a ton of well organized material. You have to fill in the blanks and annotate it just like any guide book. But if you are going to use OnlineMedEd then these books are essential as they go hand in hand with some of the videos. Just like any resource, the more you use it the more results you get from it!
So if you are interested in using OnlineMedEd check them out here: OnlineMedEd.
*Full disclosure: sponsored content. That being said, I only support brands that I believe in.*
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