All right, well, I want to welcome everyone in, we really appreciate y'all joining us tonight for what I think is going to be an exciting session and I hope one that will generate a lot of discussion. And we have titled this from interested third year to new congenital calf attending what a long strange trip. Please hear your faculty that you'll get to know and see more here in a short time. And here's an outline of what we're going to aim to do tonight and so far as cover, and it's a lot of topics, a lot of topics in a short amount of time but what we want to emphasize is this q&a discussion format at the end we're really hoping that y'all will take advantage of that, and certainly ask us any questions that come to mind at this session is for you and it's a session that we created because we think it's not something that's highlighted a lot in our field and so we want to draw attention to all the questions that there remains, I'm going to stop sharing and introduce our first panelists, who is Dr. Brian Murray, he's the director of cardiac calf labs at Seattle Children's Hospital and associate professor of pediatrics at the University of Washington School of Medicine, and he's going to get us started talking about securing and maximizing fourth year training. All right, Brian, I'll let you take it away. So I get to talk about how you find a fourth year and how you make the most out of it. Admittedly, there is no right answer to this. And most of what you're going to see here is my, my opinion, but will hopefully spark some discussion in the q&a section is out with it too. So let's start out with how you find a fourth year fellowship opportunity. In years past, the many years past, there weren't that many training programs. So it's a pretty limited number of places where you could actually train and that's increased over the years. But it's sometimes hard to figure out who's training in what years there are only a small handful of places that actually train people consistently. And so I want to thank this group of folks who have actually taken it upon themselves, and there are probably some others that I haven't mentioned here, to try to figure this process out and add a little more clarity to it, and hopefully put us on a path towards a more standardized evaluation process and application process. So thanks to this group, and I'd like to congratulate Gareth for probably the longest set of initials after his name that I've ever seen. Gareth's either very old or very smart or both, I'm not sure which, but that is impressive. So thanks Gareth, I learned a lot just looking at that. This is, so this comes from the Society for Pediatric Cardiology Program Directors, and this is a website that's I think relatively new, but I actually never really knew much about. And so this is a website, and this is actually taken directly from that website, and it publishes the programs that respond, admittedly, so maybe not everybody, but it's a pretty comprehensive list of folks that actually train both on an annual basis and those that intermittently have fellows. So this is a really good resource for not only places that have trained in the past, if they're planning to train for the future in upcoming academic years, and whether they're going to be accepting external candidates. And generally speaking, it's anywhere from eight to 12 programs a year that are training people, and what it doesn't really identify or define is how many of these folks are actually accepting only internal candidates or whether they're likely to be accepting internal candidates. This is the website for that group, and there's some other resources here as well, so I'd encourage you to check this out. It's not something that I was aware of, but it is a pretty useful resource. As you saw there, there are, like I said, about eight to 12 programs that are traditionally training, probably half a dozen that train every year, that have funding every year, and then the others are sort of here and there training, and there's a lot of variability in how these programs and positions are funded. Some have endowments from private donors, some have research funds, it's part of the departmental or divisional endowment. So there is variability, but generally speaking, again, about eight to 12 programs per year are training individual applicants. The trick with this is that there's really no standardized process for applications, and so each individual program does it a little differently. And this is something that I think that group that I mentioned earlier is trying to help maybe remedy in the future, but what you'll also notice is that there's a lot of variability in timing. And so it's in your best interest, if you're interested in a fourth year, to start reaching out to program directors and cath lab directors early in the process to try to identify places that are training, whether they're going to have an internal applicant, whether they're only going to accept an internal applicant, and at least start to make inroads in that process. The group that has put that together actually has a manuscript that's going to come out in publication, I think, in the near future, so that'll be a useful resource, and they have a larger survey that they've put together, and those results will be published as well. But I think what we've learned or what they have learned is that kind of some of what we knew, but also gives us a direction for the future, is it's important to reach out to centers individually. There's no standardized application process at the moment, and so it really behooves you to be proactive in that process. So the next part is kind of centered more around how you land a fourth year position, how you set yourself up, and then what you do when you get there. I don't know if anybody remembers Jack Handy. His thought for this is when you go for a job interview, ask if they were press charges. I probably wouldn't recommend that, but that's deep thoughts from Jack Handy for anybody who remembers that. So making yourself a good candidate starts early. I think the most important thing, and sometimes something that gets overlooked is just learn to become a good cardiologist. I would say that the people that I know that are the best interventional cardiologists are also really good physicians and really good general cardiologists as a rule. And so the idea that you have to hyper-specialize very early and ignore some of the other tenets and aspects of pediatric cardiology training I think is probably false, and it's in your best interest and your patient's best interest to really become the best cardiologist, general cardiologist you can, which means taking advantage of all of the opportunities that are available to you doing your core fellowship. Internal candidates, by the time most people realize that they want to do an interventional fellowship, they're already obviously in a fellowship, and so most people, if they're lucky enough to go to a place to train someone every year, then that makes it a little easy. If you are in one of those places and you would be an internal candidate, this is a chance for you to really make yourself known, and it really is a long interview process. You want to make yourself useful and demonstrate to the folks that are in charge that you are worthy of that position. Being academically productive, it follows along those lines. I think a lot of people obviously do some academic work during their fellowship, but those who kind of stand out will stand out, and that's helpful in your application process. Now that I'm sort of on the faculty side of things, I think this is really important, and this is a hard thing to do sometimes, is finding faculty mentors that can vouch for you in the field. This is a pretty small field. Everybody knows everybody, and so there's a lot of weight placed on letters and phone calls, and so if I get an applicant or an application, I'm going to call the folks at their home institution, and I'm going to ask them what their impressions are, and that's really important, and so making or developing in-depth, good, fruitful relationships with other faculty members is important, and then this question of, should I stay or should I go? There are benefits of, should you stay in your home institution and train in one place and never leave versus training in multiple places or working in multiple places, and what's the value there? There are benefits and drawbacks to both. I don't think there's a right answer. I personally am sort of one of those people that believes that a broad breadth of experience is helpful. You will find that people do things very differently depending on where they work, where they trained, what their experience is. Nothing's really, there's no wrong answer, but building a toolkit out of those experiences can be really valuable. Programmatic fit, this is really hard because you basically get a day to kind of figure it out unless you're an internal applicant, so for those people who are internal applicants, that's obviously a different part, a different aspect, or a different thing to think about, but programmatic size and volume, what educational opportunities are afforded to you? Can you attend conferences? Are there other job requirements as part of your fellowship training? For some places, that's how they partially fund your fellowship is they use you as a sort of an adjunct faculty member to help generate some revenue, and that offsets the cost of training you, and you can see the results from the survey that Alan and his group put together. Case type exposure, some places are hyper-specialized in certain cases, so you're going to see a ton of a certain type of case. You obviously want a broad breadth of experience. It's hard to know when you're a second or third year fellow what that is, but it's a reasonable question to ask. Personal factors, location, family, et cetera, if you have seasonal affective disorder, Seattle might not be the place for you, but personal factors obviously should be taken into consideration as well. And job opportunities, if there's a place that is training to hire someone, that's obviously important and actually could land you a good job early on out of training, and that's obviously very valuable. And research opportunities, places that have nice research infrastructure, particularly if you're going to one place for one year, you want to have a place that has research infrastructure that can allow you to do projects quickly and efficiently. And then the bigger question is sort of the ethos of the program, which is a hard thing to figure out, particularly when you're kind of still in your core cardiology fellowship, is what's the approach to kind of growth and development in the program? And you can sort of get a sense if you ask that question, people will hopefully give you a realistic answer about how they think about how they train and develop and progress their fourth year trainees. So once you get there, how do you make the most of it? And again, this is sort of my opinion, but hopefully people will sort of agree with it. But getting the most out of your fourth year, and this is sort of developed from my experience both as a fellow and then now as someone who trains fellows. First and foremost is learn to be a really good assistant. One, it helps demonstrate that you're helpful, you're useful, people like that. But it also demonstrates that you're anticipating and thinking about what's going on during the cases, both before, during, and after. And that demonstrates to the faculty that you are really actively engaged mentally in what's going on. And it also helps, it keeps you engaged in the process and you learn to sort of think, okay, what would I do if I were the one making the decisions here? Be around all the time, be present as much as you can. And this doesn't just mean like, you know, hang out and be a cath lab rat and hang around. It means, you know, attend your surgical conferences, be present in clinic, be the face in the ICU so that when the ICU has a question about a patient that they need a cath on, they go, they look for you as the fourth year fellow to answer that question. That's a really valuable experience to learn how to provide good, timely, accurate consultations in the ICU on post-op or preoperative patients. That's a really valuable skill. Be prepared, always. Have a plan. Hope is not a plan. And one of the things that I remember and learned and have sort of internalized and teach to the fellows is, you know, you need to have kind of a series of plans for everything that you do. So if one thing doesn't work, you need to be able to move and pivot quickly into your next option. And this can be anything from simple catheter-based maneuvers to what do you do if something goes wrong? What are the likely adverse events in this scenario? Really good interventional cardiologists have all these things in their toolkit and know what the potential pitfalls of a procedure are and what they're going to do to get out of it. And that's a skill that you really have to work on and develop. You got to play the what would I do game. This is hard. So if you're in a case and it's kind of boring, you really need to be mentally fit and engaged and focus on what would you do if you were the one making these decisions? That's a hard thing to do when you really try to do it, but it's important because it keeps you mentally sharp, it keeps you involved and engaged in the case, and it demonstrates to the folks that are training you that you are in fact engaged in the case and what's going on. Identifying early research and mentorship opportunities. Obviously this is sort of a duh statement, but mentorship is a tricky one because there are people who are kind of mentors and then there are people who are really mentors. People who really think about it. They think about leadership, they think about teaching. It's really a thing that they spend a lot of time and have a lot of focus and pride in. And those people are pretty rare. And if you can identify those folks early on, they can be really valuable resources. And they don't have to be interventional cardiologists, right? The best mentor here in my institution is not an interventional cardiologist, someone that I really rely on. Be a gearhead, learn all the tools, learn all the tricks, pay attention to what people in the adult world are doing, structural, coronary, peripheral, what are the neuro IR teams doing? Be a mentor, pay attention to conferences, talk to fellow, talk to your co-fellows, talk to attendings, just learn what's out there and know your tools. And seek out opportunities to learn skills from different disciplines. This goes along the same lines of understanding your gear, which is paying attention to and learn lessons from adult interventional cardiologists, structural cardiologists, peripheral cardiologists. If you have an integrated lab with an adult institution or you do your adult congenital interventions at adult institution, for example, there's a lot of opportunity to just learn from the people that are there. And that's a very valuable, it can be a very valuable experience. And you can parlay some of those skills into what you do as a pediatric congenital cardiologist. This is sort of the more kind of touchy feely stuff, but also I think is important and probably the stuff that sticks with you the most is watching and get an internalizing lessons from people who do this really well. So building teams and relationships, how do you, once you transition out of being a fellow and a junior faculty member, how do you go on and you're going to be responsible for building teams, maintaining teams, growing a cath lab, growing a program. Watch people who do this really well, because their voice will stick in your head. Certain programs have really unique skill sets and referral patient populations that can help you develop skills in certain areas that can be an asset as you move into the junior faculty world and are looking for jobs. This is, this one's really important and really, I think it's really tricky and challenging is you spend so much of your time as a fellow trying to learn how to do stuff that sometimes you kind of miss the idea of why do we do certain things and people who are really, cardiologists who are really experienced have really have got this down and knowing when it's time to push and when it's time to not is a really important skill set and something that it takes experience to learn, but you have to start early and you want to really watch the people who do it well, because that is the voice that will stick in your head as you get farther along in your training. And then identify attributes that you want to take away as an attending, you know, modeling positive interactions with colleagues, how do they handle challenging cases? How do they handle bad outcomes? How do they manage a room when something, when things are going poorly? Find really good mentors that do that well and model that behavior. That's it. Good luck. As I'm sure for all the folks on the panel, reach out for the fellows who are listening, reach out. And if you have questions, we're happy to serve as resources. Most of us are relatively new in this field and are relatively close to the fellowship experience and the junior faculty experience. So we're happy to help in any way that we can. Thanks.

fourth year training

pediatric cardiology fellows

research opportunities

program directors

academic productivity