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Cardiovascular Emergencies

Authors

Kevin Budziszewski, MSIII
University of New England College of Osteopathic Medicine

Neil Khoury, MSIII
St. George’s University School of Medicine

Zaza Atanelov, MD
Emergency Medicine Resident
North Florida Regional

Special thanks to our 1st edition writing team

Maite Huis in't Veld, MD
Krystle Shafer, MD

INTRODUCTION

Description of the specialty
The cardiovascular emergencies fellowship gives emergency physicians more specialized knowledge and skills related to cardiovascular emergencies. These skills include, but are not limited to: reading and interpreting echocardiography, stress electrocardiography and nuclear medicine studies, and caring for the critically ill patient in cardiogenic shock or with a deadly congenital arrhythmia that is bound for coronary care unit (CCU) care. These skills will allow the fellow to teach emergency physicians, residents, and medical students, as an associate professor or residency director at an academic institution. Other opportunities include research or serving as director of an observation, chest pain, or clinical decision unit.

History of the specialty/fellowship pathway
Cardiology fellowships traditionally are a pathway exclusively available for internal medicine graduates as a 3-year fellowship. However, within emergency medicine, there has been a growing interest in this field. Furthermore, cardiovascular emergencies are an important and common problem in emergency medicine, and while emergency physicians are familiar with and have expertise in cardiovascular emergencies, there remains a gap of knowledge compared to traditionally trained cardiologists. In the early 2000s, cardiovascular emergency fellowships were developed to address this gap. There are currently 3 fellowship opportunities available. These fellowships are currently not accredited by the ACGME and there is no board certification.

Why residents choose to follow this career path
Residents have chosen this career path to develop an academic niche, to further expand echocardiography skills, to become researchers, and to serve as EM/cardiology liaisons or directors of clinical decision, observation, or chest pain units.

How do I know if this path is right for me?
This is the right path if you have a strong academic interest in cardiovascular medicine and/or are interested in teaching and have a passion for all things related to cardiovascular emergencies. If you are interested in observation medicine/chest pain units, but the observation fellowship does not fit your wants and needs, this could be the right fellowship for you.  

Career options after fellowship
These include academic teaching positions, as well as administrative or director positions in a clinical decision/general observation/chest pain observation unit. Consider the retention rate at your program of interest. Some tend to offer attending positions to their fellows, while others pursue those with outside experience.

Economic and lifestyle benefits notwithstanding, the decision to pursue fellowship should ideally be based on personal interest and satisfaction. Completing this fellowship does not necessarily mean you will have different career options or make a higher salary compared to traditional emergency physicians. Emergency medicine pay is largely specific to the location and environment of practice. This sentiment is adequately captured by Dr. Ali Fzard, an emergency cardiology fellowship graduate:

“I did the fellowship knowing that I would take a pay cut that year when compared to working clinically as an EP. However, the fellowship has opened many doors for me. It helped set me apart from other candidates during my job search and I think helped me secure my current clinical position at Baylor University Medical Center in Dallas, which I am very happy with. It also allowed me to stay active academically. I lecture to medical students and EP's on cardiovascular emergencies topics, author chapters in cardiology related publications, do clinical research, and help my entire health system develop best practices and guidelines that are used throughout our entire hospital system! I recently also became an assistant medical director of the ED, and the medical director of our hospitals observation unit.”

Academic vs. community positions
This fellowship prepares the cardiovascular emergencies fellow to work in both the academic as well as the community setting, but is more an academia-driven fellowship. Physicians who have more interest in research and/or education of medical students/residents/fellows tend to gravitate toward this fellowship and go onto academic positions. Training in this fellowship would give one the appropriate knowledge base and skill set to teach how to perform and read ECHOs, how to interpret stress tests and Nuclear imaging as well as teach observation medicine. You will be known as the Cardiovascular expert in both the academic and community setting, giving you a niche and improved job security in both settings.

A graduate of the Stanford Fellowship was hired by an EM group to help open and run several Chest Pain units and had his MBA paid for by them. Others have chosen to take research-heavy positions working with cardiologists and EM faculty to create multi-center hybrid cardiovascular and EM-focused projects.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
There are 3 programs currently:

Differences between programs
The curricula and emphasis on different aspects of training will vary, but most are similar in clinical, research, and teaching responsibilities.

Length of time required to complete fellowship
At the time of this writing, all three available fellowships offer one-year positions. 

Skills acquired during fellowship
Clinical management of cardiovascular emergencies, cardiovascular emergency related research and general research skills, proficiency in echocardiography, stress testing protocols and their interpretation, advanced electrocardiography interpretation, pacemaker/automatic implantable cardioverter-defibrillator (AICD) interrogation and interpretation, left ventricular assist device (LVAD) management, and chest pain/observation unit operation.

Typical rotations/curriculum
Curriculum traditionally includes: echocardiography, cardiology consult service, nuclear cardiology, stress electrocardiography, cardiac critical care unit, arrhythmia/electrophysiology service, pediatric cardiology, and research. The didactic curriculum will often include emergency medicine lecture series, cardiology lecture series, and joint emergency medicine/cardiology conferences. Fellows are also typically involved in resident education both clinically and in didactics, and may work part-time as a clinical instructor/attending.

Board certification afterwards?
No.

Average salary during fellowship
This will vary at different institutions. Most fellows get paid as a clinical instructor/fellow. Some programs allow you to work part time as an attending.

PREPARING TO APPLY

How competitive is the fellowship application process?
There are limited positions currently available. However, the application pool is also traditionally small. Usually 2-3 fellows are interviewed and 1 is chosen, but it varies on the number of applicants in the application cycle.

Requirements to apply
Candidates must have completed an ACGME approved residency in emergency medicine and be ABEM board certified or board eligible in emergency medicine.

Research requirements
Research is not required, but can strengthen your application especially if the research is related to the field of cardiovascular medicine. Strive to have a project near completion prior to the submission of your fellowship application.

Suggested elective rotations to take during residency
Rotations to consider include cardiac anesthesia, ultrasound elective with focus of TTE and TEE, chest pain observation units, inpatient cardiology services, research electives, and pediatric cardiology services. Experience in point of care ultrasound is helpful, but not required.

Suggestions on how to excel during these elective rotations
Treat every day as an interview day and strive to make the best impression possible. Arrive early, stay late, and be a team player. Read daily to expand your knowledge base. Make sure you are courteous to everyone and provide the best patient care possible.

Should I complete an away rotation?
Because there are only a few fellowship programs, it may be worth considering an away rotation at one of these institutions to get a better feel for their program and to “audition” there. This is not required and plenty of physicians have obtained fellowship positions without completing an away rotation.

What can I do to stand out from the crowd?
Build a CV with activities that clearly demonstrate your interest in this field while also demonstrating your leadership abilities.

Should I join a hospital committee?
Hospital committees can be an excellent way to develop your leadership skills, assuming you have meaningful contribution to the committee. However, your CV should reflect your interests, rather than a mash-up of unrelated projects.

Publications other than research
Publications other than research – such as chapters, case reports, blog posts, podcasts, etc., especially regarding cardiovascular topics – can certainly support your application. These are excellent opportunities to further educate both yourself and your fellow emergency medicine physicians. 

How many recommendations should I get? Who should write these recommendations?
Traditionally three letters of recommendation are requested, one of which should be from either your program director or department chair. The other two should be from faculty members who are strongly supportive of you and can attest to your interest in this field of medicine. While not required, if you do an elective in a cardiology-specific rotation, a letter from that elective can be very helpful.

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes. Remain competitive by continuing activities that build on your interest in and knowledge of cardiovascular topics.

What if I’m a DO applicant?
No foreseen issues.

What if I am an international applicant?
Contact each program directly to inquire.

APPLICATION PROCESS

How many applications should I submit?
An applicant should apply to all places s/he would seriously consider a fellowship position if offered.

How do I pick the right program for me?
Look at the curriculum and assess if it matches your interests and career goals after fellowship. Location is also an important consideration.

Common mistakes during the application process

  • Missing application deadlines.
  • Submitting an incomplete application.
  • Failing to demonstrate specific interest in cardiovascular emergencies on your CV.
  • Submitting letters of recommendations from faculty members who are weakly   supportive.
  • Not being known by the program of interest prior to applying.

Application deadlines
Contact each program directly for application instructions and deadlines. Generally, candidates should start the process roughly 1 year prior to their planned fellowship start date.

Tips for writing your personal statement
Avoid simply repeating your CV in your personal statement. Instead, focus on writing about what sparked your interest in cardiovascular emergency fellowship and end your statement with a summary of your proposed career goals after completing fellowship.

Is this a match process?
No.

What happens if I don’t obtain a fellowship position?
Take a step back and examine your application with a critical eye to identify weaknesses. Ask programs for tips on how to improve your application. It may be worth asking your program director from residency to review your application for weakness as well. Once you have identified these areas, spend the next year working on improving your application and re-apply. Worst-case scenario, it is possible to build your niche within this field without attending a fellowship. 

INTERVIEW PROCESS

How do I stand out from the crowd?
Come prepared with questions about the fellowship that cannot be easily found on the program’s website. Make sure you can clearly voice why you wish to complete fellowship and your plans for a career post-fellowship training. Practice with a member of your residency leadership prior to your interviews.

What types of interview questions are typically asked?

  • Why are you interested in a cardiovascular emergency fellowship?
  • Why are you specifically interested in attending our program?
  • What are your strengths and weakness?
  • Tell me more about “blank” that you list here on your CV.
  • What makes you unique?

How many interviews should I go on?
You should attend all interviews offered, assuming that you only applied to programs that you would seriously consider attending if offered a fellowship position. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading
Mattu A. Cardiovascular Emergencies. Dallas, TX: American College of Emergency Physicians; 2014.

Important skills to practice while in residency to prepare for fellowship
Focus on ECG interpretation and echocardiography skills. It will also be helpful to gain research experience during residency, because many programs also focus on cardiovascular emergency-related research opportunities. In addition, leadership skills and familiarity with observation/chest pain pathways would be beneficial. 

Tips on how to succeed as a fellow
Fellowship is a unique time to expand your skillset under the guidance of mentors. Take advantage of all opportunities offered, such as with research, course work, certifications, and/or advanced degrees. Read every day and strive to become an expert within this niche of medicine. However, make sure to also stay balanced and make time for your family, friends, and hobbies to prevent burnout. 

CONCLUSION

Additional Resources

Journals

  • Journal of Cardiovascular Emergencies
  • Cardiovascular Ultrasound

Blogs

Podcasts

 

National organizations

Conferences

  • American College of Cardiology Annual Scientific Assembly
  • American Society of Echocardiography Annual Scientific Assembly

How to find a mentor
There is no central website that helps link interested candidates with leaders in this field. To find a mentor, consider networking by reaching out via email, attending national meetings, etc.