I'm a believer that you don't necessarily have to be hyper-specialized when you start applying for programs. I don't expect applicants for fourth years to have very particular sets of skills. It's nice if they have spent a lot of time in the lab, but as I said, I do want them to be good general cardiologists and have taken advantage of the opportunities that there are during their fellowship. I think there are people who have unique skill sets from additional training, which certainly sets them apart. You know, the ACHD thing, which has obviously become a common question in the chat, is something that's really interesting. A couple of the folks who clearly come from mixed adult pediatric backgrounds who have adult interventional experience, whether it's coronary or structural, do offer a very unique skill set that is actually increasingly valuable. It's important to figure out ways to incorporate them into a practice that can really take advantage of those skills. When I'm looking at applicants, the biggest thing that I'm looking at is when I want to speak to them and get a sense of their personality and whether they would fit and what their goals are. But more importantly, as I said in my talk about mentorship and developing relationships with faculty members, the impressions of the people that I know and trust in those institutions are really valuable and important. And if they can't really vouch for someone or they have some doubts or concerns, that obviously carries a fair bit of weight. So I think you want to try early on, and this can be hard, particularly if you don't go into fellowship wanting to be an interventional cardiologist and decide partway through. You may not have those relationships and that can be tricky, but I do think it's important. Having read a lot of letters now, you can really tell when someone knows somebody well and when they don't. And so pay special attention to who you try to collaborate with and work with and get to know, and then the folks who you ask to vouch for you or to vouch on your behalf. Because those letters, those phone calls, those emails, they do carry a lot of weight and it's really important. There's a lot of discussion that goes on in the background when fellows are applying for fourth years, because it is a small community and there aren't very many fellowship spots and everybody knows everybody. So I do value the impression of the cath director or the program director from where this person is coming. And so I think that's probably what I value the most. It's very hard for us to get to know you in a day or two, just as it's very difficult for you to get to know us in a day or two. It's very challenging to make that leap. And so those references from people that we trust are very valuable. Can I just piggyback on that for a sec? I think you'll hear that common theme where you keep on talking about people like mentors and people that are vouching for you and making calls and things like that. And I remember going through that process the first time I had, I thought to myself, why is it everything that's based up until this point has been on objective measures and these are now subjective measures, right? If you really think about it, in 10 years, if you get a phone call from a former co-fellow, I get a call from someone like Alan and says that you really have to take this fellow or you really have to take this early career faculty. It means something different in that context than someone who you don't know or haven't heard of, or potentially has a bad reputation calling you with the same information about another applicant. And so that's really where it all seats is. It's not necessarily this shady business deal, but it's about connections and who can understand what you're all about, how you act around people, how hard you work, the things you care about. And that goes through people who know other people, just because that's the best way to get that information in a trustworthy way. Very good. You know, there's a lot of questions coming through regarding the ACHD, and I got to be honest with you. I'm just going to, from the 10,000 foot view, I think ACHD is a bit of a Pandora's box right now. We're all trying to figure it out. Would you all agree with that? I think that each program is figuring it out and it is a pink elephant in the room, if you will. I think there's people like Tacey who did several years of ACHD training, there's people like myself, I believe Brian, who are also just ACHD board certified. And every program does that a little bit differently. And so we don't have all the answers to that. Your question's a great one, Anne, I see that about ACHD interventional training, but I think that's something that the congenital field as a whole, and that's congenital structural interventionalists are going to really have to figure out and it's going to be what it looks like now, hopefully will look a lot different in 10 years. Would you all agree with that? Yeah. I think, and I think I want to specifically address the couple of people who've asked questions who are coming from the adult side, which just in full disclosure, that's not my background. I did med PEDS and a pediatric cardiology fellowship, but there is increasing interest as the population grows and ages and folks who came through the adult cardiology pathway. And I think there's, like you said, we're going to have to think outside the box a little bit and how to incorporate all of this, because I think that folks with that training are incredibly valuable, but they probably, you guys probably fit into a program in a little bit of a different way. It can be hard to bring ACHD cath into a purely adult institution. I mean, I think it's almost impossible if you don't have an involved ACHD service there already, right? You can't, if you're an adult trained interventionalist who's doing, ASD and PFO and mitraclet, and left atrial appendage and things like that, and you have a lot of great structural skills. But ACHD cath is a combination of the actual skills in the lab and also really, really understanding the physiology of congenital heart disease patients. And so certainly for those who have then done formal ACHD training, in addition, that's a great start towards that, although it's not a hundred percent of it, because there's a specific set of diseases that you tend to see a lot more of in the adult population. And there is still something missing if you haven't seen those diseases in the childhood realm. So in my opinion, the best programs are the ones that are going to be able to work together and collaborate. This is all about collaboration. For me, ideally, you have a collaborative program where you have a pediatric trained interventionalist who's interested in ACHD, and then an adult trained interventionalist who's interested in structural and ACHD, and you can work together, because there's things that as a primarily pediatric trained person, like I'm completely uncomfortable with coronary issues. I don't stent coronaries. So it's real awkward for me in a standalone children's hospital, every time I run into somebody having a STEMI. So if you can create that group, it's an amazing, you know, you can do anything if you have that group together, but it really does have to be a collaboration, and that takes program building on a high up, you know, hospital to hospital, program to program, hospital leadership level to invest in that kind of program, program building and to understand that two cath doctors may need to be in the cath lab at once, which like doesn't look great for RVUs, but it takes good care of the patient. So that's kind of what I would say. If you're coming at this for the adult side, and you're interested in getting more into ACHD, the first thing you need to do is identify a pediatric trained interventionalist, you know, congenital interventionalist who's going to be willing to take you under their wing, and who also wants to learn from you and from the great expertise that you bring. Yeah, I think that's exactly right, Tacey, and I want to, Anne asked a specific question about how much training or what constitutes enough interventional training. We did, we've done this in the last year or last few years, and we take what actually one of my co-faculty members on the ACHD side who does some of the ACHD work with me is actually came from the adult side and did an adult, did a coronary year. And again, I think I agree with Tacey, represents an incredibly valuable skill set, but it has to be nurtured in the right setting. The way we did it with that particular individual is they had expressed an interest early in their adult intervention or their adult cardiology fellowship, and then throughout the course of their coronary year, did some, you know, some interventions on the adult or the ACHD side with us at the adult hospital, which is where we do most of our ACHD interventions. And then as part of his two-year ACHD fellowship, pretty much devoted an almost an entire year, we structured it in such a way that he did all of his clinical time in, you know, on, you know, in terms of inpatient and consults at the clinic and those sorts of things within a, within a year. And then he almost devoted an entire year to interventions and that meant spending a lot of time at the children's hospital to understand and learn how to take care of babies and neonates as well, even though he wasn't going to do that, but that, that is how we built that year. And that's a, that's a one model. There are many other ways to do it, but I certainly feel like that person was well-trained. He ended up staying on faculty here. And so as Tacey pointed out, we do, he and I do a lot of training, a lot of interventions together on the ACHD side because we bring different skill sets. That's really great, Brian. That's the advantage of being in a general hospital. There's a question, a prejumah in the chat asked how open are pediatric interventional fellowships to accepting adult trained fellows. And I think that depends a little bit on, on, on where you are. I would say that that's actually probably fairly challenging in, in the, in the current climate. And probably the only chance of that is in a general hospital type program. I think it's going to be hard to find a standalone children's hospital who's going to take a, a, a purely adult trained person, if only for just issues of sometimes you have other responsibilities like you're expected to, you know, take call and answer questions about pediatric cardiology. And if you don't know how to do that, then that may not be, may not fit into the, the workflow of, of the program. So while I'm not going to say it's impossible, I think there are, there are challenges there and you'd have to really kind of explore that and find the exactly right, right opportunity. I don't know how you, the rest of you guys feel about that. Yeah, I agree. It's all this institution dependent. And I think that knowing the strengths of that institution is really the key, you know, there's, there's strengths and weaknesses that are very specific to a group of people and how they, especially if they're, they've grown within, within the same institution for a very long time. But I think it all depends on your personnel, getting to know them, whether it's coming in as a new applicant or a few years in after you've gotten to, you know, tap into new resources. Sometimes the resources that are used are not the ones that are available. Sometimes there are other ones that you can take advantage of that are creative and, and, and even a standing, standalone children's hospital, you can take advantage of some of those adult colleagues. Like I said, I mean, these are topics that aren't necessarily highlighted in a lot of sessions. And so I'm glad you'll join us and it's not going to end. I mean, as Tacey said, the upcoming SCAI, Pisces, is going to highlight some of these topics and as mentioned, there's the FICC or FIC group that I'm a part of, I would be remiss if I did not say Ryan Callahan and Audrey Marshall have done an incredible job coordinating that. They've been the spearheads of that group. And we do have some publications under review currently. So those are going to be helpful insofar as training in the CAP world, but, but all that being said, I can't say thank you all enough to everyone who joined. I think it's great. And I look forward to more sessions in the future about, about all this.

cardiologists

collaboration

mentorship

adult congenital heart disease

training opportunities