Hi, everybody. Welcome to the webinar series. We are going to be talking about starting and staying strong. Sky when creative weapon series. This is sponsored by sky supported by Abbott, Abiomet, by Chesey, CSI, Medtronic, Philips, Siemens, Haldaneers, and Zoll. This is the faculty that is going to be involved in the panel discussion today. Dr. Sutton is the assistant professor at University of Michigan. She is in the division of cardiovascular medicine section of interventional cardiology. Dr. Nishtha Serene is the medical director for women's heart center for Providence Ascension Hospital. Dr. Regina Lee is an interventional cardiologist with Denver Heart in Denver, Colorado. She completed her internal medicine residency at Dartmouth Hitchcock Medical Center in Lebanon. Her general cardiology fellowship at Georgetown University MedStar Washington Hospital Center and an interventional cardiology fellowship at George Washington University Hospital in Washington, D.C. Dr. Sheila Sani is an interventional cardiologist at Garden State Heart Center, part of Hackensack Meridian Health Medical Group and JFK Medical Center. Dr. Poonam Velagapudi is a structural interventional cardiologist, assistant professor of medicine and associate program director for cardiovascular medicine fellowship at University of Nebraska. Welcome to all of you. The agenda today is going to be a brief introduction, followed by discussion on four basic points. We're going to be talking about recognizing readiness for independent operator role, identifying opportunities for involvement with industry, staying at an institution of training versus venturing to a new domain of practice, and the critical role of social media in active networking. So thank you for that introduction. We actually rebranded. So I'm an interventional cardiologist in a community-based practice that was running for about 40 years with my father. And I've been there for about five years now. We've launched a woman's heart program. I'm the director of that. And I'm involved in doing a lot of general cardiology as well as prepping cases for obviously my interventional career. I work in two main hospitals that are part of one of the largest health systems in New Jersey, Hackensack Meridian Health. And what's interesting is that one of my main labs is seaport-restricted. So if anybody's looking for jobs out there and you don't have cardiothoracic backup, that's kind of what happens in New Jersey as well. So I can do my type A, B, sometimes peri-BC lesions there. But anything high risk, I usually take off the table and I bring to a high-risk center. That's now Jersey Shore, before I was bringing it to Mount Sinai in New York. Just a little bit about me. Yeah, hi. My name is Poonam Valgapudi. And thanks, Nishta and Nadia, for having me. I'm an early career interventional cardiologist. I do coronaries and structural heart work at the University of Nebraska Medical Center. It's been about three and a half years. And this is my first job after training. And we are a university hospital. We do have a lot of referral hospitals around the state of Nebraska. And it's a very high risk. We have a lot of high risk coronary work and we have a lot of high risk structural cases as well. I think the advantage of being at the university is to have a great collaboration with our CT surgery folks, our imaging, as well as the other heart failure and other specialties. So I, per se, am working hard on building the mitral side of the structural program. And that's the MitraClip program has been taking off over the last year and a half to two years. In addition, I'm also the Associate Program Director for Cardiology Fellowship. And I really enjoy teaching. And it's been a wonderful experience working with fellows and mentoring them, in addition to actually having the COVID issues that have been going on over the past two years. And I'm so glad we're hopefully getting over that. So I'm glad to be here and participate in the discussion. Thanks, Munam. Regina, do you want to go next? Sure. Hi, everyone. I'm Regina. I'm one of the interventional cardiologists at Denver Heart in Denver, Colorado. I work mostly out of Swedish Medical Center and also Rose Medical Center here in the city. This is my second job at a fellowship. I graduated from interventional cardiology at GW in Washington, DC. And I was previously at Bayview Physician Group in Virginia, in the Norfolk and the Virginia Beach area. So happy to participate today. Thanks, Regina. I'm going to hand over to my co-moderators. Nadia, do you want to introduce yourself? Absolutely. My name is Nadia Sutton. It's really nice to be part of this panel. I've really enjoyed working with Nishta this season on this career development series. And this particular webinar is mostly focused on like those that the first year or two after you're starting after fellowship. But certainly, we can delve into other areas of career development as needed. But my background is I'm an interventional cardiologist, obviously, at the University of Michigan in Ann Arbor, Michigan. And I did all my postgraduate training here, as you mentioned. My clinical interest is in coronaries, very coronary focused. And then I have a research focus in vascular aging, and have a research lab focused on that area of interest. So that's kind of my background. And yeah, I think since we've all had an opportunity to introduce ourselves, we can kind of launch in and we've sort of started to touch on some of these issues. But I think, you know, one of the things just to start off with is, is maybe just talking a little bit about, you know, that transition from finishing fellowship to starting in your first position, any particular tips or challenges? You know, maybe mention if you it sounds like I think most of you all actually switched institutions, I stayed in the same institution, but, you know, some of the unique aspects of your transitions, and maybe Poonam, do you want to start? I think it's very important. The training years are really important in, you know, learning all the vast variety of cases, I think, because that's the time when you have somebody standing behind you. And so for myself, you know, I really tried to scrub in as much as I could, both during my interventional as well as my structural year. So starting off as an early career operator, it's not only you're trying to find your niche, but you're also trying to get to know a new lab, new lab personnel, and then new colleagues and everything. And so it's really, really important that you understand what you are able to do and what you, you know, you really need to ask for mentorship. For example, the structural cases are not just simple, straightforward cases. So I had my partners scrub for the first few weeks to help me, you know, get onboarded with all the understanding of the lab, how it works, how the, you know, surgeons or the techs and how everything works. So it was really helpful to have them for the first few weeks. And then after that, you started doing cases more independently. And that's when you actually learn a lot of things that you think you already know. But, you know, that was a big transition was doing structural cases on my own. For the coronary work, I think we had a very good exposure and training for two years. So I technically considered the structural year was a good year to practice my coronary skills as well. So I was a little bit more confident with my coronary work, but yet we would review the cases with another partner and kind of work on, you know, how do you do this case or with other mentors outside, how do you do this case, you know, think about these steps and what are you going to do, what complications could happen, and how are you going to work with those. And always schedule those cases on days when, you know, there's another operator going to be around. Now, the challenge with being at a university setting is we also have trainees and interventional fellows who, you know, just being out of fellowship, I knew how important it was to actually give hands-on work to your interventional fellows and general fellows, right? So that was a difficult balance that I tried to, you know, it took me at least a couple of months to realize how much I could let the fellows do and how much I should be doing on my own. It was more like to keep the complications or anything as minimum as possible. And I think it took me about three to six months to actually let my fellows be primary operators or start doing all that kind of work. But then, you know, I really kept a close eye on what they were doing. So I think it's a real, you know, balance between understanding what you can do and what you should do actually, to be honest. You could do a wide plethora of whatever, you know, but I think it's important to understand what you should do and not do in the first few months. So I think that took me about three to six months and then my partners were very helpful in helping me achieve that, you know, balance. Yeah, that is a great point that you bring up about working with fellows when you're first finishing, you've just finished your training and now you're the person who is overseeing fellows in the cath lab. Because I know I also had that responsibility as well. And I would just say to the fellows to show some grace towards your early career attendings. I think it's a very stressful time because you want to make sure your patients do really well because you know that everybody knows that you're new and if there's any complication, even if it might've happened to anybody else, if you're, you know, very early and green out of fellowship, there's always this sort of sense that, oh, well, maybe it's because of a lack of experience. And so I do think that, you know, giving up that, you know, hands-on aspect with patients right out of fellowship and overseeing somebody else's, it can be a challenge. So I think, you know, what you touched on about, it took about three to six months. I think that, I mean, for me, I think it even took longer than that before, you know, I felt that I could sort of back off a little bit from, in that perspective. So thank you for bringing that up as well. So, and then Regina, do you want to talk a little bit about your transition and some of your experiences? Sure. So some of the things, one thing that I think really helped me while I was in fellowship, because around April or May of interventional fellowship, I started having a little anxiety about being on my own, you know, in a few months I'm like, oh my God, am I ready to do this by myself? Especially with the high, you know, the high stress STEMI cases. So I don't know everyone's programs are structured differently, but at GW, whenever we had a PCI, our attending would screw up with us. So for the last couple of months, I asked my attending, can you just step back and just kind of let me do this? And obviously intervene if something's going horribly wrong, but I needed her to kind of be in the background while I kind of practice being by myself. And I found that very helpful and just trust, you know, trust in your training because, you know, we've all been very well trained and we've seen a lot in our fellowship year. So that definitely helped. Another piece of advice that was very useful to me when I was starting out in private practice was case selection. So when you're first starting out, you know, just be really careful about the cases that you choose to take to the lab or which ones you choose to intervene on. And sometimes you can't choose, sometimes the case chooses you, but talking about it with your other partners and just going over films, that was very helpful to me. Someone told me that you'll be judged on the first 50 cases that you do, you know, whether any complication happens and it could have happened to anyone, but as much as you can control, you know, choosing your cases carefully, especially at the beginning, I think it gave me a sense of control as well. Great. Sheila, any comments? Now you were in a way like going to a new place, but it was also kind of coming home. So yeah, very different. If joining a community-based practice is extremely different from being in a private practice with a lot of partners, as well as an academic setting, because what, you know, when you're joining a practice that just has one individual, it's been running with one individual. So what, what I quickly realized is who I needed to know in the cath lab. And what was nice, I have to really say is that I had to get 10 cases proctored before I could do anything on my own. And I got those proctored with the director of the cath lab, which was not my father. And so one of the best advice that I received before I graduated from my program director was to find multiple allies. They would be in different practices, right? But to find different allies that could back up the case or be around. What happened, you know, in community-based practices, you're often in a cath lab by yourself. Sometimes you're the only interventionalist in the hospital. So when Regina's talking about case selection, she's 100% right. Some of those cases were STEMIs in my case, but I just wanted, I want everybody to know I started by working in five different cath labs. That was really overwhelming. A lot of them are restricted. They don't have bypass. They don't have cardiothoracic bypass and they're not that up to date. So it was old Floro. They didn't necessarily have my radial equipment. I had some things I had to kind of let them know I needed before I could feel comfortable working there. And that was really important. But knowing who the cath lab nurse manager is and how the lab runs is a really important part about transitioning because you don't want to slow down the lab, but you also need to know how the workflow goes when you're new. And so that's key. I think identifying people that you can review your cases with and learning about what you can and cannot do in the lab. So in my main lab, I can't IVIS the left main. You can imagine my frustration. So there's certain things I have to learn because otherwise we would get, it's like dinged as a complication because it's considered an intervention. So these were things I had to really readjust to. I worked with fellows at one of our high risk centers and it was very difficult, very difficult. I mean, if you can't even get your radial equipment, how can you focus on teaching a fellow? So I, you know, how I managed that was I taught them a lot of didactic, you know, or I waited until I got the guide up or explain them what a guide was. I taught them what I could when I couldn't let them have their hands-on experience. It definitely took me more than six months to feel comfortable working with fellows. And then just a little bit more about what I chose to do. I wanted a little bit more of that academic approach to my really high risk cases, post bypass, anything that was a subtotal occlusion, anything that was almost in the realm of early CTO. And those are the cases that I took to Sinai. And I felt really good about doing that. I was also living in the city. And then after I got married and I started doing, you know, a lot of work with media, it was way too difficult. It wasn't practical to take patients from New Jersey to the city. And I'm really glad I was able to network with young, like-minded cardiologists at Jersey Shore that had a lot more, you know, a lot more my style. A lot of them had trained similar to me, graduated a few years ago. And that's really where I found a good balance and a good home for my cases and collaborating really nicely with other cardiologists from other practices. That's awesome. It sounds like you showed a lot of flexibility and just open-mindedness to different opportunities that would be beneficial for your patients along the way. That's awesome. Nishtha, do you want to share a little bit about your first experiences? Of course. Thanks, Nadia. My experience is a little bit different because I went from one place to the other. From a medicine residency, I was in New York. Then I came to Michigan for my cardiology fellowship. Then I went to Mount Sinai for my interventional fellowship. And then because of my visa, I had to get J visa. So I had to come back to Michigan in Pontiac and do three years of my J visa. And then I had to do next two years of my J visa. So I had to switch two different jobs. And that meant I was looking at different work environment very, very frequently. And I was working in the past five years, I've worked out of almost 12 hospitals. And every hospital has a different flavor. I mean, I agree with Sheila 100%. It's a different culture everywhere. There are hospitals where you don't have threctomy devices, you don't even have cutting balloons, impellas could be expired. So you're in the middle of a STEMI and the transducer isn't working. So issues like that, that you don't expect. And then there is the other around where you have fellows and it's an academic institution and they have OCT and you can do OCT. So it's like a whole horizon. The one thing that really helped me was relationship with the CAT lab staff. They've been there for a long time, positions come and go, but they know what the style is. They will help you, they tell you which fellows are safer to work with, which fellows to be more cautious about. It takes a while to get comfortable with fellows. And I was very upfront with them about it just because, and I always told them patient care comes first. And I had set guidelines for them. After their seven months, I'm going to let them go up with a balloon or go up with a stent. And I always went backwards. Guide was the last thing I gave them because I was always afraid of dissection. So guide was the last thing they got. But also access, because most complications happen with the access. The one point that I found was very helpful for me when I started out of my fellowship was not to make decisions in the CAT lab once you get the images. And that was one of my attendings who taught me during my cardiology fellowship. So he would step out of the CAT lab, go out in the control room and look at the pictures again, because every time you have a complication, the first question that comes to your mind was, did the patient really need this procedure? If you have a really strong reason that this procedure was indicated and you have thought it through, then you don't feel as bad. But if there's an elective patient who comes in early in your career and the indication is soft, and then you go ahead and do a high-risk intervention without looking at the images carefully, it is tougher to get over it because there is some amount of burnout that happens every time. And it takes a while to go back to being yourself after having a complication. So I think case selection, as Regina mentioned, is very important. Being very mindful and interacting with the other colleagues is also critical. Do you want to go over the next potential discussion question that we were going to? Oh, Nani, do you have anything to add about it, though? Oh, yeah. Well, I mean, I stayed at the same institution, which has its own challenges, but it was great. It was a good decision for me. It worked out really well with my research program. And of course, when you're staying in the same place that you trained at, I already knew the CAT lab staff and had a great relationship with everybody. So that was really easy in a way. But I think that the tough part was probably the transitioning from being the fellow to supervising the fellow. I think that was a challenge. And just kind of establishing a new program for yourself. I set up a geriatric cardiology clinic. And just initially, I felt like I wasn't seeing enough patients in clinic. And now my clinic is so full that I'm constantly overbooking myself. And it's actually gotten a little bit out of control. So I mean, I guess that's the other thing is it will ramp up, I think, very quickly for most people. We just have so much need in the community. And there's so much need for cardiovascular care that don't worry when you're first starting if things feel a little bit like you should be doing more because it ramps up so quickly. So that's the only other piece of advice I have in that front. So yeah. Thanks, Nani. What about being a fellow at the same institution and then being an attending at the same institution? There's always this concern about being the perpetual fellow. And I'm sure there are some individuals who will always see me as a fellow because that's how they initially knew me. And I actually have personally tried to be very mindful that I don't necessarily see some of the fellows who I work with who have become now my colleagues in the same way because I think you kind of always have this sense like you're training them. But I mean, I just I think ultimately it doesn't bother me very much because I feel like we're all lifelong learners. We're all still learning. And if somebody sees me as junior to them, then I guess that means I still have my youth. So I'll just persevere. That's the best way of dealing with it, Nadia, right? And your work speaks to you.

interventional cardiologists

starting careers

panel discussion

experiences

challenges

transitioning from fellowship to practice