for joining us today, this Wednesday afternoon. We're gonna kind of shift gears and we're gonna have a very fun discussion today. I have these great guests today. Then we're gonna talk about the current state of cardiology fellowship programs, right? This conversation is this reoccurring theme. And those of you that were at CV Transform this weekend talked about this, right? These generational gaps. In order to successfully recruit, we need to understand each other. So we're gonna chat with our guests and take a deep dive into what's happening in cardiovascular fellowships. So we're just gonna wait a second to see if more folks join. And then we will jump right in. So really quick, our usual housekeeping, as you guys know, for those of you who have joined us in the past, the link to the presentation slides is on the bottom on the left-hand side. And on the right is your ability to ask questions throughout this presentation. Again, this is meant to be a free-flowing conversation. We want to make sure we are answering your questions. So at any point, please feel free to send those questions in. And if we don't get to them at that moment, we will definitely regroup at the end and have some open conversation. So with that, let's jump on in. So I want to introduce my special guest who I am incredibly excited and thankful for their time today. I always hate taking away the clinical cardiologist from their clinical roles as an administrator. To me, it's almost sinful, right? You meet with them early in the day or late at night, nothing in between. So thank you both. And with that, I'd love for you guys to introduce yourselves. And if you can kindly tell us about your programs, how long you've been a program director and the diversity of your subspecialty programs, right? Because that's, we're going to tell the whole story today. Thorsten? Yeah, thank you, Anna. I appreciate the opportunity to be here and always happy to be on the panel with Mukta, my partner in crime from across the city. So I'm Thorsten Leuka, I'm Cardiology, General Cardiology Fellowship Program Director at Hopkins in Baltimore. I did fellowship here in Baltimore and then did my chief fellow year and then joined as the Associate Program Director under Steve Shulman, who did this job for, I think about 10 years before me. And then when Steve retired about three years ago, I took over as the Program Director and I've been running the show here for the last three years. And initially I was a little unsure about stepping into Steve's shoes, but this is really one of the pleasures of my life to be the Program Director and be part of training the next generation of cardiologists in the field. And it's a pleasure to work with such bright and young and enthusiastic people from all over the world that train with us here at Hopkins. Thank you. Thorsten, I can't believe it's only been three years. I feel like we've shared stories and talked for longer than that. And I agree, it's like when you meet another PD, it's always like this instant connection because you know a lot of the trials and tribulations. I'm Mukta Shreevastav. I'm at University of Maryland where we have a clinically geared cardiovascular disease fellowship with kind of a concentration in clinical research that may take the form of med ed or more so clinical based. And based in Baltimore, I think our fellows see a lot of the same challenges probably also at Hopkins, an urban setting, a lot of socio demographic challenges. I took over the PD role, I think around 2016 or 17 for my PD, Mike Benitez. And I really share the sentiment. It's truly a privilege. There are a lot of trials and tribulations, but it is one of the most rewarding, gratifying parts of my role at Maryland. Thank you both. And that's really setting the stage for this conversation, right? That these folks are real people who will eventually be taking care of us, right? And our patients and our family and our neighbors. So hence why we really want to understand each other. I'm just gonna give some facts, kind of tell the story before we jump into our active conversation here. So really quick, Gen Z. And again, we were just chatting about this. We weren't quite clear what generation we all lived in, what category, right? But boomers, we know that now they're declining at the same time, they're not going anywhere as we all know. We can't afford physically for them to leave, right? Cause there's so many patients in the pipeline. We just need to figure out how to transition them, right? At the same time, the millennials, right? 50 million millennials are now part of the workforce. That being said, it's very, the boomers versus the millennials, right? Millennials we know are born with technology. Millennials, the boomers were not. Us Gen X in the middle, we've kind of straddled both worlds, right? So part of the conversation here is to kind of bridge it all together. How these millennials and boomers, how we're going to work together in the future. So really quick, this is a slide from our MedAxium portfolio that we show often, right? And it's showing that one in four cardiologists, 25% are over 61. So we know that again, they're aging, but they're not going anywhere for a number of reasons. That being said, they also don't wanna continue the call, right? They're not gonna continue the full schedules that they've been working for the last 40 years, the last 30 years. So that being said, we need to backfill those, that FTE, right? On the flip side of that, the fellows in the pipeline, right? So this is based on the 20, June, 2022 data. So I'm hopeful this looks familiar to you guys, right? So there's 32, 3,282 active fellows, right? Of those, a third, obviously every year, three-year program, complete training. And about 50 to 60%, I hope this sounds right. Please correct me if I'm wrong, pursue subspecialty training, right? So they finish their general cardiology fellowship, and then they go on to EP, intervention, adult congenital, a number of subspecialties. And then of course, there's all the non-accredited subspecialties now too, right? So that actually only translates into about 435 new general cardiologists transitioning into the workforce every year. And then at that same time, how many of them are pursuing this advanced training? At the end of that year, there's 753, again, give or take, because this obviously doesn't account for all the non-accredited specialty programs that are transitioning into the workforce. So this also creates an interesting problem, right? There's nearly twice as many subspecialty trained cardiologists going into practice than general cardiologists, right? And as we know, we need a lot of general cardiologists right now to create that bandwidth to see all these patients. So it's a little bit of a dilemma because if you go through all your training, as you know, Mukta, as a interventionalist, you wanna be in the cath lab, right? The structural heart guys wanna be doing this TAVR, right? So sticking them in clinic almost feels like we're punishing them, right? And that's not the intent. It's just trying to create the bandwidth to see everybody. So that being said, this is what Google says. And of course we assume everything Google says is right, but this is these primary differences between these millennials and these boomers. And again, we're kind of picking on the boomers because it's bringing together these different multi-generation workforces and how we're working together. So this understanding that millennials are different, their values, their work styles, and obviously their technology proficiency, right? So they're one end of the spectrum. And then on the other end of the spectrum, and again, most of you guys were trained by boomers, right? You took over for boomers, that you're working in practices that were built by boomers. And they're known for their incredibly strong work ethic. Nobody questions them, right? They're on call 24 seven, very traditional values. And obviously their cautious stance toward technology. I always say they're creatures of habit. Creatures of habit, change is hard for them, right? And then you have the millennials who, again, every time my kids text me, I have to look up what they're saying to me because I don't understand, right? So it's complicated, right? So that's the setup. That's the backstory that we're trying to fill in the gaps today. And that's why you guys are here. I'm hoping you can shed light on what's happening in fellowships today. What's different from when you guys were fellows? What are these reoccurring themes? And again, as you said, these intangibles, right? It's not stuff that we read in the journal. They're not research studies, but it's truly affecting our workforce. And we need to figure out how to successfully recruit new clinicians into our practice. So understanding them is part of that, right? So we're gonna jump right in. I'm gonna poke the bear here, right? For all those millennials watching and hoping you guys can shed light. So again, they all say that millennials don't work as hard as boomers. True or false? What do you guys think? I see our fellows working very hard within the framework given to us by the ACGME every day. And I would disagree with the statement. I think our fellows are very hardworking young people that take good care of our patients that wear many, many hats. I think the expectations nowadays are far greater than they used to be in terms of what certifications they need to have, what co-cads they need to meet. If they wanna have a research career and where to get the grants from. I think there's so many different facets of this that it's hard to just brush everything over one comb and say that millennials don't work as hard as boomers. Yeah, I mean, I have to agree. They work differently and the nature of the work. I mean, even when I think when I'm on consults and I work with our fellows, I remember having paper charts. And so if you had a new consult, there is a sort of a defined limit to how much chart review you could do. We didn't have epic. Now our fellows have the ability and are also cursed by the ability to be able to look back many, many years in our medical record and then multiple other medical records. And they can even go to doctor first and confirm as a patient taking their med or not. And so I think the burden of what they do when they're at work is different and in a way more challenging and more work in that particular framework. I guess this alludes a little bit to our senior attendings who will be willing to stay here till seven or eight or 9 p.m. finishing charts and rounding sometimes and staying and sticking around. And maybe that approach to work is different and not shared by newer generations. They're more like, let's work hard, let's work smart and efficiently also. I appreciate that. And I think that's the nail on the head, the work different, right? The after hours and all the call, I get that, right? Like a lot of us grew up, I'm married to a physician, the long hours of call, because when he's on call, I always say I'm on call too, right? And it changes the family dynamics and this new generation doesn't want that. And that's fair, right? But I hadn't thought about the burden, which you mentioned, which is critical, right? Within this nine to five hours, which it's really not nine to five, we know that, but all the information that they need to absorb because of all this technology that's available now, right? That's a lot. And often it's not feasible to think that they can do that during a regular clinic visit, right? So I appreciate you pointing that out. But what about this whole, again, calls? Being a cardiologist requires a lot of call. So the folks that don't wanna do the call, how does that translate for the rest of the faculty? Do you hear that? I'm surprised that you're stating they don't wanna do the call because our fellows get their schedule at the starting of the year which has their call schedule on there. And that's the requirement by the program to do. And just comparing the calls that our fellows doing today to the calls that I did when I was a fellow a few years back, I think that's somewhat comparable. I wanted to touch base on one thing that Mukta said about the efficiency and work smarter. I'm impressed every day. And if my fellows teach me every day on how to utilize technology to do the job better and how to synthesize the data in a more efficient way and come up with conclusions, probably more efficient than I used to come up with these conclusions. And so I think there is a strong focus on how the job is changing. And we are at the threshold or brisk of AI I'm getting into medicine. And I think we're just scratching the surface of what's gonna happen in the next decades to medical education and how we practice medicine in general. And I think our fellows are at the frontier here. They're the trailblazers to have the way for that and teach us, teach the older generation. And I would call mid-career at this point on how to tackle all this. Yeah, I agree. They're gonna be teaching us, right? Yeah. It may be a little bit tangential to that, but just with regards to the type of trainees coming out in the workforce, the only worry I see with this kind of new paradigm where there's so much chart data, I do see a lot of when there's a consult, when there's an admission, so much time is spent pre-reviewing and then the balance of what's spent really getting a good history that sometimes I feel is starting to get eroded compared to prior generations where they didn't have the benefit of all this chart. So I wonder how that impacts the type of clinicians that are coming out of training and almost like an anchor bias that happens because you do so much chart review in their minds and 80% of the time they're right. They already have a diagnosis, an idea of what they think is going on. They'll even make recs to a team, whereas prior generations, I think, did a lot more at the bedside. And there's a balance of how much utility there is to making the diagnosis at bedside versus just that patient-physician relationship. But in as much as it impacts how good of a clinician you are coming out of training today and you're bombarded with so much available chart review. And that's a good point, right? So when you're making the decision that, again, this is a non-clinician administrator talking though, right? But when you see the team around the bed making the decisions, you're seeing your faculty, right? That's how you kind of almost legitimize yourself, right? The ones who are stepping up, who are asking the right questions, who are making recommendations. If the fellows are doing that in the background, how do they distinguish themselves, right? How do they, I don't know, how do they distinguish themselves amongst the senior faculty, right? Does that even make sense, that question? I think our fellows today get the job done similar to past generations. And I think that our fellows are providing excellent care for the more and more complex our patients. I think some of the cases that we see today, which probably is somewhat related to the options that are available now are so much more complex than they used to be in the past with all the mechanical circulatory support options, new valve procedures, new toys in the toolbox that Mukta is using in the cath lab. I think that our fellows are tackling this complex of field with grace and expertise that they have to acquire in the same time that older faculty had to acquire their training. But again, I think that the field is so much more complex these days than it used to be. I think that that's probably more the focus rather than they are not working as hard. Go ahead. Oh, in adding to that to the rate at which medical literature comes out now, even compared to when I was a fellow is just exponential. So even the task of keeping up with new literature, new guidelines is greater, I think for trainees today. I just wanted to, so some of the reoccurring themes that you hear from the fellows, right? So I mean, you know, so some of the reoccurring themes that you hear from the fellows, right? What are their worries? What are they concerned about? I mean, you guys go through dozens of fellows every year. What are those reoccurring themes? to be qualified for the job ahead of them is a big worry of fellows. I think that the landscape of jobs is probably shifting. I think it's clinical work is an important piece. Generating our views is an important piece. Here at Hopkins, we are training clinicians as well as physician scientists. And I think that looking back to when I was in training, I think the balance was probably half and half between physician scientists and people that do more clinical work or fellows that do more clinical work. I think this is shifting towards fellows doing more and more clinical work these days because they're seeing what the jobs out there are. And I think, Anna, you pointed that out that we are only graduating, I think, about a thousand fellows and almost half of them or half of them go into subspecialty training. So there is a dire need to train more excellent clinicians. And I think all fellows want to be prepared for that. They want to gain as much clinical experience as they can during their training. They want to get as much COCATS level two or three training as they can. They take more and more boards to be qualified for the job ahead of them. And it's similar to me. I mean, I took general cardiology boards and I took lipid boards and I'm a general cardiology that practiced prevention and I do some time in the CCU, but seeing our graduating class, the imaging modalities that they are trained in, that they're certified in, it's impressive when what they squeezed into three years to become the experts that they are when they graduate. Yeah. Yes. It's like seeing new college and medical school applicants. It's like, you know, I feel like I wouldn't get in today because of how packed their experiences are and accomplishments. And in terms of what I've seen, I've seen third year fellows come back to the echo lab to do just kind of voluntarily read more echoes because they worry about that. In some ways, their period of time that they've had as a trainee is extended from other residencies where you may have completed a residency, then you're independent. Here they were a resident and now they extended that for three more years to remain as a trainee. But that leap, whenever you make it where you're the attending, I think always generates some anxiety. And so I think as Thorsten mentioned, you know, just being competent and not making mistakes when they go out. He also debriefed with a couple of fellows when they were looking for jobs and what they liked about a job was when the practice really delineated some of those things, like what is the RVU expectation? What is their clinic structure like? And when they compared with jobs they weren't as interested in, that's what they identified as something that was lacking. So I think one thing they do worry about is what is their actual day-to-day work life going to be like when they're, you know, at whatever job they're exploring. And I think that's a legitimate question, right? Because we don't often teach them this in their fellowship, which again, we were chatting previously about the business aspect of cardiology, right? It'd be really great to find a way to integrate business understanding RVU, service line development, program development for fellows so that when they're, you know, come on board as clinical faculty, you know, they know why they're doing what they're doing, right? And they know how to advocate for themselves and they know how to build programs and they know what kind of data they need to keep an eye out for. So that's all a great question. And actually Thorsten, just going back to the fellows don't want to do call, what I meant by that is, again, we're a membership organization. We get to, you know, travel the country meeting with different members and a lot of these practices that are looking to hire new docs, they say that there's a lot more negotiation and they're not seeing eye to eye when they're hiring these new career cardiologists, right? Because they're very, they're much more specific and probably rightfully, right? Before we just made an offer letter and it was very generic, right? It was a template with letter, you're on board, this is how much money you're making. Now it's pretty granular, right? How many weeks on call, how many patients per session, especially in the non-academic practices. So they're seeing a lot more like, I'd rather make less money, shockingly, because I don't want to do as many weekends on call and I don't want to do as many inpatient weeks. And that's a real, that's, it's not a, it's different, right? It's problematic in the sense that you still need to find that, you know, people to fill all those slots, but it makes it different before you just assumed you had this many clinicians and they were going to do all the weeks. That's no longer the case. So it makes it just different, right? When you're bringing people on board. At the same time, the older folks who do all that time, they often point fingers and say, wait, how is that fair? Right? But, so this is the complexity of also knowing more and just being more, you know, concerned about your life that you've trained and worked so hard for, right? And you finally get to practice it. I don't know. What do you think of that? Does that make sense though? That request on their part? Yeah, I think it's a little bit on what the opportunities are that are out there and what is the graduating workforce that will take the opportunities. And the opportunities are so many that I think trainees, graduating trainees can pick what they want to do and they can, I think more than in the past, speak up and say what they are not willing to do. That's just the way that this goes. If there's more opportunities than graduating fellows that this will create this culture. Yeah. It's really a buyer. It's a fellow's market because. And that's good. It's a shift and we need to recalibrate, but there's nothing wrong with it. It's just understanding that. That being said, we need them. They're incredibly valuable right now. And going back to the technology, they're the ones that need to teach, again, the boomers and us Gen Xers, right? How to apply and how do you use it as complementary to practice, right? And what do you, that's another question for you. You're a senior faculty. Are they open to fellows educating them, right? That taking that reverse role. Sorry, Anna. Maybe if, okay, I wanted to come back to one point, though, what you mentioned about the, let's call it the family friendliness of the workforce. I mean, we are incredibly happy and proud that we every year have many babies that are born within our fellowship and that our fellows have the opportunity to take maternity and paternity leave. Hopkins is offering that now. When I recall when I was a resident and we had two children during residency, I had a half a morning off after our children were born and then had to go back to do call. And our fellows now get actually time off to be with their family, to spend time with their family. And I think that's the right thing to do. I mean, I'm coming from a culture in Germany and Europe where maternity and paternity leave is a given and many people take as much as up to a year. It's a little different, I think, in the United States. But I think it's about time that all fellows have this opportunity that they can have families doing training and that we are accommodating that they are able to do that. Yeah, I agree. It is so refreshing. And even as female counterparts, when I had my children as an attending and we're all type A, we've all been people with generally strong work ethic. And you always feel it actually, to me, has been kind of nice to see my male colleagues also take paternity leave because it kind of validates I was obviously off for a number of weeks. And even our first year, we had two first year fellows who had first year 10 years ago, I would feel like there would be no way we can figure out six weeks off for a first year fellow. And we had two in one year. And it just works out if you feel like that is what you just do, like that's not an option. So I think that whole cultural shift has happened in the background that certainly has implications for the graduating fellows. Yeah, so I agree. That's something the United States has lacked, right, is our maternity leave, right, and paternity leave. In fact, it's quite embarrassing how bad we have been over the years. That being said, I feel like it's my job to kind of poke the bear here. So I hear both sides of the story. They need time off. It's fair. That being said, cardiology fellowship is already a short period of time. And there's a lot that they're trying to absorb, learn during that time period. During that time frame. And then they go out on maternity leave or paternity leave. And it's even more condensed. They're learning, right. And some people have more than one baby during fellowship training, right. So then you graduate and now you're a practicing clinician. You've missed a big chunk of learning, right, clinical learning. So I hear both ends of the story. Having, again, married to a cardiologist and administrator and as a wife, right. You know, it's all aspects. It depends who you're asking, right. But sometimes those new career cardiologists aren't quite ready to be independent, right. So it's also that understanding that they also need more time. I don't know. What do you think of that? It's, you know, people say that too, right. Yeah, we actually try to prepare our graduates better for the job ahead, particularly during their third time where we practice gradual independence. So when I'm in the CCU with a first year, I'm usually more involved than when I'm in the CCU with a third year where they are very capable of running the show. And I'm just standing right behind them and checking in with them to make sure that things are going along. And on some services, we practice a pretending approach where the fellow runs with the team and checks in with the attending. And the attending obviously sees all the patients and writes notes. But the fellows are more and more independent to be ready for this next step. Because I think the transition from fellow to faculty is probably one of the biggest steps in one's career when you're going from a supervised, sheltered environment to being in charge and you make the final decision. And these final decisions can be very relevant for patient care. I think that's important to prepare the fellows for this next step. On the other hand, I mean, the support system that are available these days, I mean, medicine really is a team sport and it's many experts that are taking care of patients and are contributing to the care of patients. It's not that the fellows are, once they've graduated, are completely alone. And obviously the teacher is always around and in the background and happy to help. But I think it's important to prepare the fellows for this next step. It's a very important step. And the better they are prepared, the better they're going to do and the better patient care they're going to provide down the road. Yeah. And I think as program leadership, we do have to be cognizant of meeting training metrics. So as much as accommodating these sort of societal positive shifts, there are, I think there are good measures in place, like the clinical competency meetings that are held twice a year and multiple faculty contribute and determine is a trainee competent. And ACGME also outlines the number of days you can be off in one academic year. And then there can be an exception if you really think that trainee has missed time, but they're on track versus recommend that they extend time. And I have had specific conversations with fellows to kind of drive home that there's no stigma, there's nothing wrong at all to take the time off you need now. This is a time that never comes back with a new child, but not to be too leery of taking an extra month or two at the end to really hone your training. And we have had a trainee do that. Just take some extra time, a month or two to finish up requirements and make sure they're ready for independent practice. I do think it's important on our kind of stewardship that we are cognizant of that and that we're not sending, trading one positive for the negative of sending someone not well-trained. But I don't know they go hand in hand with the paternal and the parental leave or any kind of leave because you have trainees that do all three years and they leave not fully competent as well. But yeah, I think there has to be kind of a cognizance of that and making sure that trainees leave truly independent. Yeah, no, I appreciate that insight. And that's great to know that the fellows, that you encourage that, right? You know, the stigma of, I mean, these are highly competitive, highly motivated, very smart people, right? Who spent their entire life checking off the box, right? Very A-type. So to take that step back and say, I need a couple more months, that's hard for them. So I appreciate you putting that out there and giving fellows that opportunity, right? I think a lot of people could benefit from that. So that's reassuring from my perspective, knowing that, again, when you're checking off those boxes, right, and cramming a lot into it. And I think that technology creates another burden for fellows that, I'll be honest, I hadn't really thought about before, right? At the same time, they bring this amazing value into new practices too, right? That a lot of, you know, pre-existing practices that have been in place for decades really could use that new energy and that new blood, right? Having seen that perspective. And I think it's recognizing that they're very much needed. And it's almost like partnering a boomer with a millennial kind of thing, right? Because of the technology, the value that they add. I don't know, does that make sense? Is that reasonable to think that, you know, there could be some kind of partnership in the future? And mainly so they're more sympathetic towards each other kind of thing too, right? Yeah, I think it's a symbiosis almost, right? Where you could make the argument that the young graduating faculty or fellow to faculty is benefiting from the expertise and from the experience from older folks that have been doing this for a while. While vice versa, the new kid on the block may be able to teach technological hints and tips to the older generation. I think that might be a better way of framing it, that this is really a partnership. And I mean, that's how medical education works. We learn from the giants in the field and we are going out trying to become the next giants in the field to train the next generation. So it's a handover of the expertise to some extent. Yeah. And I mean, like you said, we're sort of so liberally using the term boomers and kind of creating these distinctions. And I don't know if you agree too, Ersson, but I feel like in academic medicine too, there should be a lot more. I was really happy to see that ACC created a senior section because I don't think there's a lot of conversation about what do you do when you find yourself not, you know, should a senior practice member be doing as much clinical work as a new person? There are practice models where you do all your time up front and the seniors don't have to take calls. And that's not popular, though. I don't think our fellows like those models when they're entering a practice. And so there is a role for symbiosis and, you know, new ideas come from these younger folks and they're integrating AI. And when they write their clinic notes, there's all this software now that you don't have to, you know, kind of like these scribes that are real people or even just software that will scribe for you. And a senior person may find that extremely helpful, but they have to overcome the hurdle of learning how to use it. And so I think there's also a role for transitioning what you contribute to a practice, depending on what stage of life you're in. And I think my attendings, to me, it seems like they never considered anything but just doing what they did for 40 years. Whereas our generation, I start to think about things like I don't imagine myself cathing for another 20 years. I won't. I probably would transition into something, whether it's in a clinical sphere or industry. So I think there are different ways, too, that people approach when they're coming out of fellowship training what they're going to do long-term. That's a good point, right? Kathy, and being on call when you're 75 years old for a STEMI, it seems unreasonable, right? At the same time, I've been there. We've had faculty members older than that, right? And we live in the Northeast, snowstorms, and it feels like we're asking a lot of folks who have dedicated their entire life to taking care of people that we should have a better plan. That's another webinar, because that's an interesting conversation, too, right? The transitions. But it's also a very good topic. I guess, you know, what's your biggest concern for these current fellowship programs, these fellows that are transitioning? What's your biggest concern for them as they transition into their real, finally real life, right? Everything they've been working for. I haven't been too worried about them. I truly think they really thrive. I think, as Thorsten said, it's a great market for them. So I don't hear back. I do hear back, but it's very positive. I think I was quoted some rate of trainees, you know, fellows who change jobs within the first three to five years. And I think it's like a third or something like that. And I don't know what more contemporarily that number is. But most of our fellows that, you know, this is just a gestalt, but they're quite happy in the jobs. They do a good job up front of researching what they want and looking for all these things that matter to them. And also, we're both at these urban centers where the complexity you see in training is just so magnified compared to what you need to thrive in the community if they're taking a job out in the community. And if they stay at an academic center, you have all these other faculty that really take away a lot of the fear. You know, everyone's around you. It's a team sport in academia. And if you're more independent and autonomous, the only thing we worry about are skill sets like TEE, where we're not sure someone is going to be able to fly right off the bat. And we'll often even kind of say that in a very tactful way that this training may benefit from some oversight or skills like TEE in practice. But I have generally been very relaxed when I feel like the trouble and the challenges are during training because what they do here is so much harder than what they have to do out in practice. Yeah, I would echo that. I think that all fellows generally do very well. The majority of our fellows go into academic practices. And I hear wonderful things about the leadership opportunities that they're taking in clinical medicine and societies. I worry more about the physician scientists because I think that job is getting harder and harder. I think funding is getting harder to obtain. It's more competitive with many changes happening currently on the horizon. I think to motivate young folks who see what clinical opportunities, what financial opportunities they have going into clinical medicine, to motivate them to take a physician scientist job and to apply for grants and to do this, it's getting harder and harder. And that's what I worry more about. I think the clinical folks are doing very well. I would agree with Mokhtar. I'm glad you brought that up. Right. The political landscape right now has made it incredibly unsettling for the clinician scientists, right? And some of the reason your fellows ended up with you guys is because they're large academic institutions that do really great research. Are fellows pulling back from submitting for a K grant? Is that kind of no longer the plan or what's happening? What are they feeling about that? Yeah, I think it's more challenging. And I think fellows ask important questions on what the opportunities will be down the road. What are the success rates of getting a job on a K? What is the K to R transition? How successful they will be down the road? I think that is something that many young trainees think about, particularly if they have a family and they need to support the family. I think these are all considerations that play a role. And I think the current funding landscape is not helping this discussion. I think it's more challenging now than it was when I was graduating to find a job where you get protected time, where you have the opportunity to think about projects, to develop projects, to write grants. I think that's something that we need to foster and shelter because, again, the science is an important part of medicine and we can only be as good clinicians as the scientists that supporting the clinical work. And so I think that's something that we need to support. Yeah, it's a challenging environment right now. Actually, speaking of the clinician scientists working on a project, doing their day-to-day job, I recall way back then when I was an administrator, we had a lot of fellows moonlighting. Are they still doing that? Because, again, there's so much compressed learning in this period of time. Do they still do that? And the reason I ask is we have some really great partners within MedAxium, the ProLocums and Moonlighting Solutions. They're always trying to figure this out too. Is it the same people that they're chasing down, right? The people that want the work, is it still fellows? Because before, the pay scale is still really low for a fellow, right? But there's been, you know, a lot of the fellowships are unionized now. The pay scale is slightly better. Again, it's still a tough environment. But now that they're not, a lot of the reason was because they were doing research, right? Even less compensated work. But do you still find that fellows are looking for those other opportunities during fellowship? I would say so, yes. I don't hear so much about it. Most of it is on site where they do have the opportunity. It's the easiest thing. We don't have to apply for a separate Maryland license. And they can sign up for these extra shifts. They have to be called by ACGME. Outside of the medical center, I'm not sure how much time or bandwidth they have to seek out. But I do see them take advantage, certainly, of opportunities on site. Yeah, I would agree with that. I mean, most of our fellows are moonlighting internally, so that we can also monitor, obviously, the duty hours for our fellows. But it's a way to subsidize the salaries, which are much better nowadays. I would agree, Anna. I would agree with that statement. Our fellows are getting better compensated. And I think that's important that they're getting better compensated for the work that they're doing. Yeah. There's a lot of complaints, obviously, about the unionization of these roles. But I'll be honest. They were slave labor for way too long, right? Especially the research fellows. That was always somewhat sinful, right? How much work they had to do for the compensation. So it's feeling a little better. That being said, indirect overhead was all part of that big system, right? So we'll see where we go in the future. My last real kind of important question here are salaries. So again, as I said, it's a fellows market right now. Amazing opportunity for a graduating fellow, right? Obviously, working with a lot of people, hearing what some of those offers are, it's shocking to me how much, if they're willing to move and they're flexible, the possibilities for them, right? That being said, it feels like it's not sustainable, right? These really, really large salaries. And eventually, we kind of need to recalibrate because reimbursement only continues to go down. What are fellows saying? I mean, because obviously, it raises their expectations, right? And they hear about these bonuses to move and buy homes and so on. Do you guys hear about this stuff? Do they talk to you guys about this? They do. But I think I would say the majority of our fellows are making their decisions more based on family location and the kind of work that they really want to do. Because yes, you can make a lot of money, but you're going to work very, very hard for that. And you may have to relocate and take a lot of calls and do a lot of things that you may not be willing to do. You'd rather take a slightly smaller salary and have more, as you're saying, that work-life balance. So I think that these decisions are going into that. And the majority of our fellows, I would say, are taking jobs rather based on other criteria than just the financial part. I mean, the finances play an important role, particularly if you're trained in this country and you have student loans. And there's a lot of that already that you have accumulated. These are all important factors. But I don't think that the salary is the sole driver of the decision. The fellows make in terms of jobs that they seek out. Yeah, I would really agree. And there's a lot of focus, I feel, on having the ability to have a niche, even for people going into general cardiology. Some of them have an interest in cardio OB or prevention or imaging, but they're not going to do a full additional year of training. But they're looking for that, which I think is a good indicator of looking for things that are going to provide more long-term satisfaction, gratification than the salary. And we have a couple of speakers that have been really great. Victor Cotton, who is a MDJD who runs his own kind of physician counseling service. And he talks, he gives this talk annually and really gives this framework. Speaking to what you said, Thurston, that like there's no free lunch in medicine. If you're going to get paid a lot, you're really going to work for it. It's probably going to mean going to multiple hospitals and all the other ways that you're going to really pay for it in your time, which is really your most precious commodity. I love that you just brought that up. There's no free lunch, right? Because again, how do you draw a crowd is those free lunches, right? You don't need fellowship, right? But it's true. There's no such thing as a free dollar. You're going to work for it. And often I worry that people don't see driving to the community hospitals is a good one, right? All of that driving around time, which again, invaluable. We need people to do that. And they should be compensated for it too, but it's also time that they're sacrificing. Interesting. So we're coming close to time here. I don't know, any thoughts that you guys could shed on our member organization as they are looking to hire your fellow babies and make them full-fledged cardiologists practicing? You know, some tips for them? I would say they're in for a treat. I think I'm very proud of the young, brilliant people that we're bringing forward, that we're training who are outstanding physicians and will take good care of patients, will take good care of us at some point. So I'm very proud of the job that we're doing. And I think the future is bright. And I think that we see all these motivated, brilliant people coming into the fellowship that get even better doing fellowship and become really competent cardiologists. So I'm very positive about this. Yeah, I have to agree. And not to really open a huge can of worms, but I think in terms of recruitment, what is attractive too is thinking about physician recruitment and also our colleagues as APPs and PAs. I think they do a lot to kind of spread that burden that you mentioned of whether it's call or the balance. And I think for practices, it's been a good model. I think it's been a good model. I think it's been a value added to have the ability to work with other physicians and also physician extenders and having that mix in a practice. I appreciate you bringing that up. That's actually a very important just practice model within MedAxiom is the APP model and letting them work to their capacity, allowing faculty to grow their practices. So I'm glad to hear, actually delighted to hear that you guys integrate the APP practices within your fellowship. So they see how it should be working. Because if they learn that way, then they practice that way. And I think that's critical to this bandwidth issue that you mentioned. Yeah. Great. And overall, you guys seem so perfect for your jobs, program director, especially you, Thurston. You're like a glass half full type of guy and I love it, right? Because it's, you know, it's delightful to know that you guys are running these fellowship programs, right? Because these are the folks, again, who will be taking care of our family members, our neighbors, our communities. And it's, you know, I feel like I'm in better hands because of you guys, right? So thank you. And again, being program director, it's rewarding at the same time. It's become incredibly labor intensive too, in a lot of ways, right? All the paperwork, all the process, the credentialing, all the process behind it. So thank you for doing that. You know, back in the day, it was basically a hobby, right? You did it on the side for the program directors. Now they've, you know, legitimized it more perhaps in protected time. And I hope that's the same for you guys. Because it's critical to do the job right and to offer the proper mentorship and education to the fellows. They need somebody that's focused and not, you know, after clinic kind of thing. So thank you for all you guys do. It's important. And it is a team sport, similar to medicine. It's not a one man or woman job. It's many, many folks that are working on our fellowship that are helping, so. Yeah. Thank you, Mukta, to you. Again, thank you for joining us. I don't see if there's any questions, any questions out there. Oh, there actually is a question. My perception is that it's difficult for fellows to assess the factors beyond compensation that will influence their happiness and retention in their first job post fellowship. Speaking about organizational culture, physician voices, and decision making. What can be done to help fellows make the best choice so that there's not a 33% change jobs in the first three to five years? What a great question. Yeah, I think it's a very important point. And Mukta and I, we think and talk a lot about that. And we actually have joined career development sessions between Hopkins and Maryland, where our fellows are getting together and they're learning from people that we call this near peer advice. So some of the recent graduates that tell the prospective graduates on what to look for. We have people that come in from all different organizational structures in medicine, in pharma, from within the hospital leadership that tell our fellows about the different aspects about what are our views, what our expectations, what opportunities are there, how to negotiate your first contract. And I think that that's a very important part that is often undertaught, the business of medicine. I think that's something that we need to pay more attention to, particularly in the ever-changing landscapes and the more complexity of finding your job. So I appreciate the question. I think that that's something that needs to be integrated in fellowship is to teach the fellows about these things. Yeah, really well put. And I would only add also when you are looking for jobs, even if... I mean, I encourage fellows to take every interview, every opportunity, because even if you don't see yourself at that practice, you gain some knowledge, some sort of... This is a whole world that you haven't been exposed to. And frankly, even I have. I stayed here where I did fellowship. And so these insights come from talking to a lot of people to make that choice that's finally... At the end of it all, there's a choice that's going to feel right. But to get to that point, you really have to gather a lot of information. Yeah, no, I appreciate your insight, both of you. And I'm going to take the shameless plug for our Wharton fellows in training program, because again, understanding the business side only makes them stronger, right? It makes them... Gives them the ability and the skill set to advocate for themselves, to be able to build programs, to understand the value that they add to a practice, right? Everybody knows that they work really hard, but being able to show the data to reflect that is even more important, right? And it's a skill set that it's underutilized, right? So I encourage all fellows to think about that in those transitional years, to understand, take a deeper dive into the business of cardiology. So with that, again, I'm grateful for both of you for your time. I know you guys are incredibly busy because you wear numerous hats, but thank you. Our audience appreciates it. And we've all learned a lot from you guys. Thank you. Thank you so much. Thank you for having us. Bye guys.

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