Hello. Hello, everyone. Thank you very much for joining our transitioning from fellow to clinical faculty webinar today. We're building on this topic that we've been discussing last week. You may recall, we spoke with two program directors from John Hopkins and from University of Maryland. We talked about fellow education and the evolution of fellow education over the last few years. And now we're going to look at the other side of the story, right? We're going to talk to a faculty member, a first-year faculty member, Dr. Gupta, who's now at UCSD, and Dr. Vergara, who's currently a fellow at Mayo. And we're going to hear it from them. We spent a lot of time talking about them, and now we're going to hear from them about their expectations. But really quick, we're just going to jump in and review some of the typical housekeeping. You guys, for those of you who join us often, know this. Sorry about that. To the left, access to the slides. And to the right, if you have any questions, then please feel free to submit your questions throughout this conversation. We're hoping it's a very interactive, engaging conversation, so we welcome all questions. So today, our special guest is, as mentioned, Dr. Gupta, who is a first-year faculty member at UCSD. She's an adult congenital heart disease trained fellow who was previously at Vanderbilt. And we also have Dr. Carlos Vergara, who's currently a CV fellow at Mayo. And we will have an opportunity to hear from both of them. So really quick, to review some of the data that we have recently reviewed. So why do we keep talking about this? We have an incredibly diverse workflow, and Gen Z all the way through to the boomers, which creates a very complex work environment. We keep talking about this. The millennials think very differently from the boomers. And then the Gen Z folks are kind of sandwiched in the middle, and a lot of our clinical leadership currently sit within that demographic. So what does that mean, right? So again, diverse workforce. We know that one in four cardiologists are over the age of 61. So clearly, they're not retiring anytime soon, but hopefully, they're transitioning into a different part of their professional career, hopefully, not as much call, hopefully, not as much time in the cath lab, but somebody has to pick up the deficit in bandwidth there, right? So who is that? So clearly, it's the new folks that are coming on board. And then from the other perspective, we know fellowship training, right? We know that how many fellows are currently in the system, right? There's 269 programs. There's about 3,000 plus fellows, active fellows. How many complete training is about half or about a third of them, actually, I apologize. And that's because such a large proportion of those fellows go into subspecialty fellowship training, right? So when you look at how many cardiologists entering, the general cardiologists entering the workforce, about 435, and then how many subspecialized are entering into the workforce, it's nearly double, right? 753, which is good and bad, right? Because when you're a subspecialist physician, you want to see, right? If you're an EP doc, you want to see EP patients, right? If you're a congenital physician, you want to see congenital patients. However, right now, we know that we have this deficit in general cardiologists, and we have so many patients that need to be seen, right? So what does that mean for the subspecialized trained fellows? So really quick to review some definitions. So, and this is from Google, so we automatically, that means Google must be right, right? So millennials versus the boomers, right? We know they're very distinct folks, and what differentiates them, right, is really technology, right? So millennials are typically associated with the work-life balance, a strong embrace of technology, and more, you know, liberal on their social issues. Conversely, boomers, we know, are a little bit more traditional. They have a very strong work ethic, and then they, I keep saying they're creatures of habit, right? So change is a little bit harder, right? Technology is a little bit harder. So we'll have to hear from Dr. Vergara, Carlos, and see if he agrees with some of these definitions, right? So Carlos, be ready for that. So I'm noticing that unfortunately Dr. Tripti hasn't joined us, so we're going to assume that she's been caught up in clinical care, right? So she will be joining at some point. So for the time being, all pressure is going to be on you and Carlos to help us shed light on some of these conversations, right? So millennials don't work as hard as boomer. What do you think? Actually, let me stop you there. I apologize. Carlos, why don't you tell us about where you did your original, where you're doing fellowship training, where you went to med school, and what your plan is. Yes, yes, of course. So as you said, I'm Carlos Vergara. Thank you for the introduction initially, and always a pleasure to be here with you guys. So I'm originally from Colombia, South America, and I did my medical school in Colombia, South America. Then came to the residency with the University of Miami-JFK Medical Center during the COVID pandemic. So 2020, I came in a humanitarian flight and kind of lived through all that initial madness of COVID, which we definitely worked very hard. Then after that, I did a match into my cardiology fellowship at Mayo Clinic, Florida. So that's where I am right now. Well, right now I'm in Rochester in a different kind of setting, but my fellowship is in Florida, in Jacksonville, Florida. And looking into doing a multimodality imaging year and focus my practice also in preventive cardiology, cardiometabolics, advanced lipids, and some of that implementation there, but mainly non-invasive, hopefully staying at Mayo, which is what we're looking for. Awesome. That's great. So thank you for that introduction. And Dr. Tripti Gupta has just joined us. So Tripti, we just went through some demographics, but I'd love for you to, again, just your background, where you did your fellowship at, your advanced training, where you are now. Sure. Thank you, Anna. Thanks for having me, guys. And sorry for joining late, just finishing some rounds. So I'm Tripti Gupta, as Anna said. I'm currently an ACHD attending at UCSD. I started with internal medicine and cardiology fellowship training at Osher Medical Center in New Orleans in Louisiana. And then I did adult congenital heart disease fellowship at Vanderbilt in Tennessee prior to joining on faculty last August. So I'm on my first year as faculty and really looking forward to answering any questions we may have during this webinar about the transition period. Well, excellent. I'm glad to hear that because we have lots of questions for you. Great. So we just were talking about millennials versus the boomers, right? You guys have been stereotyped, right? And the boomers, obviously, they're very stereotyped also. So now we have this collide of different generations in the workforce right now, right? And the reality is we need everybody to work together because there just aren't enough doctors and there's too many patients. So we need to figure out how to work together, build, continue to build, and more importantly, figure out the strengths and weaknesses of everyone and work with those, right? And you guys bring very different skills. And we're not discussing clinical, but for example, technology, which is the obvious, right, to the table. So this first statement of, and I'm just trying to poke the bear here, right, that millennials don't work as hard as boomers. We have the, as MedAxium, we have the luxury of seeing lots of people, lots of practices from around the country. We chat with lots of different type of cardiologists and for the most part, most boomers would say, and again, I'm just, you know, very broad statement here that millennials don't work as hard. I have children who are millennials, so, you know, I can argue the, I can make the conversation, argue it either way, right? They work really hard at some things and not so hard at other things. So what do you guys have to say about that? Alice, do you want to go first or should I? You can go first. Okay. Okay, cool. So I think it's a very broad question and my perspective is that it has to be based on some fact, right? And so I think millennials are good about prioritizing kind of what's important to them. And so when they do work, they're a lot more efficient. I think they can use technology to a higher level than perhaps the boomers could. And I'll just take the example of, you know, one of the things I had to learn as new faculty was learning how to be efficient in any clinical practice and doing clinic independently and seeing a large volume of patients. And it's not that I didn't want to stay till late hours after work, sort of working on patients, which is something, you know, a boomer might've done very easily, spending a long day at work, just finishing notes from clinic and things like that. But I think our focus was how do you become more efficient? So how do you use smart phrases or buttons or things within Epic, whether it's AI or technology to make you more efficient? So I think, I don't think that the millennials are per se trying to get out of work, but I think they may have different approach to how they approach work and are trying to keep that balance of work and home. I think in a little bit better balance than perhaps was done in the prior years. Carlos, what do you have to say? Yeah, I think I would agree with that. I think one of the perspective that we have had as millennials probably is seeing the aftermath of the working all the time, hard all the time, which in the personal life is translated into three divorces, kids all over the place. The guys still, or the woman is still at 80, 90 working in the hospital when you're like, what is going on? Why are you not like home enjoying what is important in life outside of a medicine? And not that medicine is unimportant because I mean, personally, it drives most of my life. But the other thing that I think millennials have identified, and we have gone through a transition of now recognizing how there's so many things that are important to become a great physician in person. And it is not only publications, it's not only how many patients you see in clinic, but it comes in ACC, right? So there's so many aspects like leadership, professional development, team building, and then having the wellness component of it, which actually makes you a better physician if you're not burnt out, because then that's what happens with the short of physician. When they start seeing that everybody's burnt out, they don't want to come into the medical field, whereas we can show that people are coming that you actually can be a good doctor, be productive in whatever you want to be productive, but also have a happy family, kids, and then have a life, then people are going to start coming more towards medicine. So I think that that's what the transition has been different generations. And as Tripti said, the use of technology, and especially now in the last five years with generative AI and everything that is kind of transitioning to something completely new, being able to be in that area where we were able to see what happened before and now and be able to adapt to it, that's a difference that you can barely see with previous generations that are harder to adapt to this. Yeah, that's actually, you already shed light on the difference between the boomers and you guys. The fact that you guys are so insightful to the balance of life, the fact that you already called out that all of us have been divorced, we're married to physicians, and that's why they're not retiring at 61 because they have multiple wives and kids to pay for. But it's true. The fact that you've already identified all of these leadership opportunities, all of these other professional roles that you guys could play, it's not just about jumping in and being a clinician on day one. And I think that's insightful because I don't think previous generations thought about the next step already, what you guys are already thinking about, what are all the possibilities? So I respect that. That's very insightful. Tripti, I'm dying to know, again, you just fit almost a year into your first faculty role, right? Your first independent role following fellowship, which you did at Vanderbilt. Was it everything you expected it to be? Be honest. We want the good and the bad. Everything and more. No, I think it's hard to have, if you're coming to a new institution, right? It's hard to have very realistic expectations of exactly what your day-to-day will look like, what the volume will feel like, what the workflow will feel like. And so one of the strategies that I sort of used was I shadowed people that work here doing what I do for about the first week while I was still waiting for my ID and my EPIC login to come through so I could learn from them and sort of get an idea of what that looks like. On interview day, you get a sense of volume and your support staff and things, but it's not until you really start that you start to see all that kind of come together. First year is hard. First year is hard, but that was an expectation that was verbalized to me from many people. So I think I expected it to be difficult, but it's been also so much fun. It's been so nice to be in the city and close to family. And I think I'm really grateful for the colleagues that I have. And so that has made the transition beautiful. So it's hard work, but I think there's also light at the end of the tunnel here. Have you found, and I know, again, you haven't been there long, but mentorship, have you already been able to carve out folks who could feed you? Yeah, I think mentorship's always been something that's very important for me. I think from day one in med school, it's something that I've sought out independently because I do well with some guidance. And so I think wherever you end up as sort of recommendations for Carlos or anyone else on the call, find those people, find who your go-to echo person is going to be, find your heart failure doc, find your EP colleague, because you will be in situations as an attending when you're making decisions about patients and you're not 100% sure. And it's very helpful to have a colleague that you can count on and ask those questions. And so I have my EP person, I have my echo person, I have my heart failure person, and I have my ECHD person. So yes, I have found some mentorship there. I've found some people who help me with research. And so I think some of that mentor-mentee relationship, I think, is a bit balanced on the mentee side to form those relationships. No one's going to come to you and say, hey, do you need help? But they expect you that if you need help, that you reach out. Is there a pressure? Do you still feel at the pressure that you should know everything? Like you're a cardiologist now, you're board certified, you should know it all? Or is there that understanding that you don't and it's okay to ask? At least the culture here is that we're very open in conversation, and it's totally okay to ask. And it's really well demonstrated by some of our senior cardiologists who ask me questions. And for a second opinion, if they're tied between two clinical decision making pathways. So I think here I have a good culture where it's okay to not know the answer. And it's okay to talk to other people and get their opinion. It's okay to not know. But well, you're, you're, you're looking well, so it doesn't look like your first year has been too traumatizing. And I'm glad to hear that it's, you're plugging away, right? You expect it hard. And it's, it is hard, right? It's, we didn't expect it to be easy, something would be wrong. Carlos, so you're listening to Tripti, she's now, you know, practicing independent. What do you hope or what do you expect out of fellowship? Yeah, no, great question. And it's great to see and hear how she's a transition because, you know, we met when she was a fellow. And I remember asking her initially, like that transition, how she was, and we haven't spoke for a while. And I think she said some key words that, that come to my mind. And with the conversations that I have with many fellows are in the transition to, to attending hood, if I can call it that way. So she mentioned, it's great to be in the city is great to be near to family. So these are kind of things that, you know, depending on who you have, or who you are, have as priorities, some people are going to be like, you know, they can stay Vanderbilt, or they could stay at MGH, or wherever they train, but, but the decision drives more not because of the name of one institution, what that's going to bring to them, but because they're close to family, for instance, because they have significant other has family nearby, I have a kid, we have kids now, and we want, you know, the my mother in law to be able to help us take care of the kids. So if that means I'm going to go to West Coast, East Coast is going to be important. My case, I don't have that right now. So that's not where one of my hopes or one of my things that I'm looking for. But, but those are the kind of things that I hear all the time from, you know, my co-fellows or other fellows from other institutions that are looking for into the transition. Not so much, you know, which is interesting, even when I speak to a lot of the people that are in the academic centers, a few of them, and I usually can identify who they say having like NIH funding or research funding and all that, but most of them are now talking to me about how their outside of hospital life is looking like, how that's going to be something that helps them move along in the day-to-day, because somehow, you know, the clinical practice and the clinical work may look similar in different settings. The system may change, but you're going to have, you know, cardiology patients at the end of the day, you have every setting you can adapt, but how can they adapt to that setting in a way that they can navigate the off-clinical work? And I think that's, you know, that's one of the millennial thing that we have is we're not only thinking of, I'm going to the biggest name institution, I'm going to the institution that, you know, is going to make, you know, my name going to be president of the ACC, but we're looking into what does this look like for me in five years, 10 years with my family, or maybe even in a year, is my marriage going to sustain this, right? Which I'm not married, so I don't know that, I'm just relaying some information. But for me specifically, my current priorities are still growing into what I want to be in my clinical setting and being involved in organized medicine like ACC. What I look for a place or where I'm looking right now is a place that would continue to allow me to grow professionally. So if I see a practice that's just going to want me to be working 100% of the time and maybe if you want to go to a conference, you take out of your vacation, and we're not going to give you much money for that, then I'm not looking to that practice because that just tells me that they're not going to be supporting my early career transition. And right now, nowadays, you know, there is so much subspecialization, so much to learn compared to probably 20 years ago. Like every day, there is so much coming up that if there is not a support for you as an early career to learn more, not only within your institution, like, you know, like Tripti looked for the mentorship and to echo intervention and all that, but also outside of your institution because you need to learn from others, then that's a practice that for me wouldn't be safe to be at. And I would be very frustrated because I would have to kind of carve out my own time all the time. You know, we understand that we as fellows even and trainees, we not only use the A2, you know, 626 or 828, we use more weekends that are off, we use the word. But if I was attending as an early career, I'm already also using all of my free time to catch up because my institution doesn't allow me to have new mentors or more professional development, then that's an issue. Because I know if I'm not married now, I'm not going to be married in five years, right? And I'm thinking about that, I don't want to be that guy. I don't know, there's a lot of subtle messaging from Carlos, Tripti, you're catching it about like my marriage, the future, like you're thinking about it, you're just in denial, just so you know. That's another webinar. So my two takeaways, though, from what you just said, one is compensation, right? Because you talked about the time to go to conferences, the time, you know, the reimbursement of doing that. So there's a lot of difference between private practice and academic medicine, right? And I'm sure Tripti can talk about this, about the compensation that's associated with the different practices, right? So Tripti, I'd love to hear your thoughts on that. Because again, you're in academic medicine, so you have protected time and it's very, that supportive environment. But when you were thinking about looking for jobs, did you have, were you looking at different types of practices? Yeah, I was, when I was looking at jobs, I think location was priority for me. So coming closer to family. So I explored a variety of practice types and patterns within Southern California, and that included academic and non-academic. And I think what really helps you decide what would be a good fit for you is trying to think about what are your priorities, and then kind of how do you see yourself in five years. And so for me, the things that I came up with was, I knew I wanted to sort of get mentorship, I knew I wanted to do heart failure, I wanted to do some research, and I wanted to be close to family, like that was it. And so outside of that, I didn't have very detailed decisions about inpatient, outpatient, things like that. But in exploring the different patterns, I think knowing that I wanted to do some research and mentor and get mentored, academic made the best sense for me. And I think for other people, it might be that they want to grow a family, or it might be that, it may not be that they want to do research, and for them, going home at a reasonable time may be a priority. And so I think trying to decide what is true to you would help people kind of make the best decision about whether they choose to be in academics or non-academics. Yeah. Do you think, thank you, I appreciate that. Do you think knowing how compensation is derived at, is part of that decision making, do you think it's valuable? And obviously, I'm biased in this opinion, right? You guys know that I'm very supportive of fellows, business education of cardiology, right? I think it's critical. Do you guys think, and again, we should be very transparent, you guys both participated in the Wharton Fellows Program, but do you think it was valuable? And do you think fellows, that should be kind of a standard practice of exposing them to that education? I completely believe that and spread information about the business essentials course to other fellows because I took it in the fall of the year that I was interviewing for jobs. And it was perfect timing because I learned a little bit from the business side about what recruiters or department chairs are held accountable for. At the end of the day, the hospital is a business, right? So they are looking for what kind of value are you bringing to institution. And so when you show up and you don't know what kind of value you're going to bring to an institution, then there might be some discordance because they'll say to do X, Y, and Z, and you may not want to do X, Y, and Z. But as you understand sort of what brings in our views, how much echoes clinics, things like that, and you sort of have a rough template of how you can add value to an institution, then they can take that and go with it. And so I think having some background about that whole system was really, really helpful to tailor my interview as I interviewed at an academic place versus a non-academic place because I think the takeaways for both are different. And so I was able to sort of modify my interview for e-book practices based on what I learned from the course. So yes, I think it's essential for every fellow to take some course similar to that. Carlos, would you agree? Yeah. No, absolutely. I think there is a difference when you are like trying to trace your future when you're like in med school to residency, residency to fellowship, because most of the things that you're putting in the personal statement, the interview is that is all these dreams of how you want to be the great cardiologist or how do you want to do this, add this to, you know, research, discover this, discover that, help people, all that. But then the reality is that now when you're a fellow and you're starting to think of what's going to happen after being a fellow and then transition to that part and you start talking to leadership, you know, money speaks. And you don't want to hear that, but that's the reality of it. And as you are in clinical practice, you realize that, that, you know, as much as you want to do everything you can, if you don't have a clear business plan or how to get that money, then patients are not going to get medications, then you're not going to get the new PET CT machine or the CT machine. And then you're going to be just at the mercy of everybody else. And especially nowadays that it comes to, you know, if you want to choose and be empowered of how your career looks like, and you're not invasive cardiologist or you're somebody that is one of this, that doesn't have great reimbursement, but how can you make, add value to a practice? And you can look for ways of how, you know, where is the console value going to come from? Who do I partner with to be able to show them my business model actually makes sense for your practice. And I'm thinking about that as a fellow versus getting into my graduation. And then all of a sudden realizing that, oh, if I don't have this plan, if I don't think like this, then I'm just at the mercy of the recruiters or them telling me what I need to do versus I'm telling you, this is what I can do. And this is what I can bring as a reimbursement and money to the practice or to the hospital or to everything. And there's more potential in three, five years. So understanding that aspect in the business of cardiology has really helped me actually navigate those conversations towards trying to secure a staff position. And I think without that, it wouldn't have been as easy because I would be still speaking, you know, the daydreams of how I want to be this amazing cardiologist leader in medicine. And it's like, okay, how are you going to do that? Well, you know, that's part of it. Well, everything you guys both just said is music to my ears, obviously. I truly feel that everybody, fellows eventually become faculty. And if they know how to, how the business runs, they can not only advocate for themselves, they could help build businesses quicker. And not only that, you just kind of speak the same language, right? It's not such an adversarial relationship with the hospital. It's more of a, you know, of a working relationship, a functional working relationship where everybody's looking to move things forward. So I appreciate that you guys see the value in that. And it was just the tip of the iceberg, right? Everybody does need an MBA. We know that. But knowing a little bit is powerful for you guys, right? And I often say everybody has a story to tell. And we often tell it through the data and knowing how to control the data, the variables that go into that formula that tell your story is important, right? So good. So really quick, moving on, Tripti, you had missed it in the beginning. We saw a slide where there's about, I don't know, let's say a thousand fellows, general cardiology fellows who graduate every year, but half of them, more than half of them go into subspecialty training, as you know, right? So at the end of the year, there's actually more subspecialists that are entering the work for the cardiology workforce than general cardiologists, which is good and bad, right? Because again, if you're an adult congenital heart doc, you want to see those type of patients, but you're not necessarily going to fill your schedule on day one. So at times you have to see general cardiology patients until you build a practice. What has been your experience so far knowing that you're a subspecialty trained doc in this world of, you know, if there aren't enough cardiologists to see patients? That's a great question. I'm glad you brought that up, Anna. My practice, by choice, is a 50-50 split between ACHD and GenCards. And I did that intentionally because I feel like seeing the general cardiology patients has just exposed me to the greater UCSD cardiology program in terms of working with fellows, EP, interventional imaging. I read General Echoes one day a week. And so there's a lot of exposure that I get to internal medicine, the rest of UCSD, and I know who I am and I know who they are, that I would not have been able to do had I just come in with sort of the narrow lens that I'm an ACHD doc and I do this alone. And you know, it offers a lot of perspectives, I think, on a weekly basis when I do general cardiology. My thought processes are faster and patients are simpler. And when I put on my ACHD hat, then I get to, you know, really do what I enjoy. And it's difficult, but it's short-lived. And then I can go back to doing general cardiology the next day. And so I like that type of variety in my week. I like that it not be monotonous. And so I strongly would encourage for people who do subspecialize to not lose their general cardiology skillset also. That's the other thing that happens once you subspecialize is you start to forget general cardiology. I work really hard to build those skillsets in fellowship. And if we don't keep using it, we will lose it. For better or for worse, our cardiology practice is, you know, growing so quickly. We're learning new things every day. And just missing general cards forces me to keep up with literature and the newest things. And I think that makes me a better doctor, even for my ACHD patients. So I think both things feed off of each other. And so I'm really grateful that I split it the way I did. Eventually, I think by years three to five, I will transition to full ACHD, or maybe I'll keep one general cards day. I wouldn't mind it. But I think it's a good strategy that worked for me. Awesome. I love that's a very mature comment. I mean, aside from you're getting to know people, the system better, right? The demographics, the community, it's a lot more that you're learning at the same time. I do respect the fact that you went into it open minded, right? Because most people just want to do what they've been trained in, right? And it's really hard in the beginning, because you can't fill their schedules. And they automatically, again, this is the administrator speaking, are a big loss to the system financially, right? And you hate for people to feel that way when they see the numbers, but you're helping to find some balance in what is often a broken system. And not only that, there's too many patients, right, and not enough people. So creating that bridge for now is a nice plan. Carlos, what do you think about that? Because you're going into subspecialty training. Yeah, no, I think, you know, Tripti's point is great. And that strategy that she's using to be able to integrate into a bigger community is amazing. Because that's true. I mean, if you're only your little niche, then probably most of the greater community, especially in a new system, is not going to get to know you and you're not going to get to do the interactions and networking that you need. I think right now, one of the disconnects that a lot of academic places can make have is that they show only that subspecialty, mid-career kind of mentorship, where they're only focusing this. So some of the people that are not exposed to speaking to others in the real world may think, oh, this is how life looks like, right? I'm just going to go into interventional, structural, and then within structural, I'm just going to train really hard in mitral valve replacement or, you know, a repair, sorry, transcutaneous mitral valve repair. And then that's what I'm going to do because I'm going to be the world expert where you go to the reality. And the reality is that when you're a structural interventional cardiologist, probably the market is very saturated and you're going to have to do 50% of general, if not more, in most of the practices that you're looking into, unless you remain into an academic system that can be also saturated. So I think one of the good jobs that organizations like ACC is doing is trying to integrate now more private kind of practice kind of perspective and also community practice perspective, because that way fellows like me get to interact with the people that are out there and start getting kind of grasping what the real world looks like, am I going to only be able to do, you know, if I want to focus on lipoprotein A, am I going to be able to do that? And then I come to find out, no, most of the people that are doing, for instance, preventive cardiology, which is what I want to do, are also seeing general cardiology patients. And there is very a minority that actually just see high-risk primary prevention, cardiometabolic or only, you know, these patients from this population. So then that sets me into, okay, I need to think about, you know, my transition into something more realistic and see what tools I need to be able to be useful, and not only for a practice, but also that I could enjoy in a bigger picture and allow me to have that, you know, that application. So that's why I decided to do multimodality imaging, for instance, because it's like, okay, this is going to be something that I can apply in general cardiology. I can be involved in everything. I can implement a lot of things. And beyond that, I can do research with prevention and doing application of CT, and then doing my extra learning in cardiometabolics and advanced lipids. And I'll have my population that is going to be a lot of, you know, primary prevention at risk, but I'll also, you know, have all the knowledge and the integration to be able to do my general cardiology and go beyond, if I want to remain in an academic system, beyond the general cardiology training, which is great. But now, as time goes by, if you don't specialize a lot, and that's why probably people are sub-specializing so much, is because if you don't really sub-specialize, then the role for general cardiology without sub-specialization is going to be more in the community programs or prior practices and just seeing a lot of volume patients versus integrating to an academic system where even if you're not going to do 100% your specialty, you're also going to do general cardiology. They also are looking for this, you know, specialists that are bringing something else to the practice or to the system. I don't know if Rupti agrees with that. Yeah, I do. I think I was trying to think on a more broad scale. You know, if we were like some other countries where we had a very big referral base of primary care physicians or primary cardiologists, then I think we could say, okay, we can all subspecialize and have a free-flowing referral system. But my understanding of our healthcare is that we don't have that solid foundation. And so oftentimes patients see a cardiologist for the first time when they have their first heart failure event or first MI. And so until we have a strong referral system like that, I think the need is in the general cardiology space. So we may choose to subspecialize, but the reality is that there's so much need that providers will have to sort of help out and see those general cardiology patients, regardless of their subspecialization, because these patients need a doctor in order for somebody to refer them to Carlos for their lipid management, right? So they need to see a general cardiologist, most likely, or a primary care physician to get referred to subspecialty clinic. So I think my approach has always been to be a little flexible and kind of go where the need is. A, because it's fulfilling, and then two, because it helps take care of a small fraction of that need. No, that's insightful from both of you. I appreciate that. But yeah, we need general cardiologists, period, right? And that the primary care, the lack of, depending on where you're in the country, the problem is slightly different. So we obviously can't speak for everyone, but yeah, in general, there's a lack of primary care docs too in the referral system. Most tend to hold onto the patients for too long, and by the time we get them, it's problematic, right? We would love to have Carlos on day one, but unfortunately that's not, we don't get to see him in the beginning, right? Hopefully in the future though. So Tripti, tell me about what do you think, what were you not prepared for, transitioning from fellow to independent clinician? What caught you by surprise? For me, honestly, it was the uncertainty of initially seeing some of the not perfect patients and sort of coming up with a surveillance plan for them. So I'll tell you, without compromising any HIPAA laws, I saw a young patient who had a mid-range EF for no apparent reason. And so then my brain started thinking about, did I read the echo correctly? Let me show this to somebody else. Why does she have a cardiomyopathy at this young age? And am I missing any symptoms? So it's that whole pattern when you're a new attending, of what am I missing that I wasn't ready for? Because as a fellow, I think when you're not sure of a plan, you have the attending to go ask. And when you're the attending, you can ask people, but you also have to learn to deal with that sense of uncomfortableness. And sort of when, who do I ask for help? When do I ask for help? How do I continue to manage pieces that kind of just don't make sense and make sure I don't miss anything that's gonna harm the patient? So I think that feeling caught me off guard initially. Well, as a non-clinician, that sounds scary. So yeah, Carlos, what about you? What did you learn? Carlos, what about you? What is your fear of going into practice, of finally being done with your training? Yeah, no, that's a great question because I was actually just speaking about this with one of my mentors, who happens to be in the leadership of my program. So I think he's more of a mid-career. And I can very openly also speak about this stuff with him, luckily. And I'm right now in the Mayo Clinic echocardiography board review, and I'm preparing for my echo boards in July. And then you see all these concepts and you see all this stuff that are so, so fascinating. But a lot of times it's like, oh my God, there's so much things to learn. And I was speaking to him, you know, I very much know what I'm gonna do with my life in terms of what I wanna do as a professional, as a micro focus. But at the same time, you start getting into these branches of, oh, what if I learned this within CT, within MR? What if I learned this in echo? I'm gonna lean it because at some point somebody is gonna come and is gonna need this. I'm gonna need to learn this concept. And, you know, you start realizing that, you know, there's so much information that yes, when you're now you're a fellow and I can actually just reach out to any of my expert attendings and everything. But then at some point you're gonna be by yourself and yeah, you may not have the time or, you know, the thing of, I'm gonna knock at the door right now. You may have some contacts and then you're gonna be able to talk to people later, but you're gonna have people in front of you and then you're gonna be making a lot of decisions and that's by yourself on you. And the uncertainty of not knowing what's gonna come in and then maybe you didn't read about that or, you know, you came out of the lecture at that moment and then you forgot to go back to that concept and then you didn't see it. And then the rarity comes, right? So I asked him, you know, how do you handle after, you know, 15 years of practice, this feeling of you don't know enough, you need to, you know, train more. And that's, I think that's the loop that some of us go in into, oh no, I need one extra year after three years of cardio or you need two extra years after the extra year even, you know, we start adding more, adding more training. A lot of people, I think it comes from the fear of I'm not gonna know enough when I come out. And majority of my attendings early career and mid career, maybe Tripta is gonna be able to say the same, is they tell me the first, you know, 30 years maybe of your early career is gonna be actually where you learn the most more than in fellowship. So just realizing that no matter, and this is also people that have been training, you know, supper specialties and seeing a lot of things. So you realizing that no matter how many years you train, you're gonna go out there, face your fear and still not know everything. And you're still gonna have a curve and you're still building that, you know, kind of network that is gonna be allow you to reach out to people whenever you encounter these situations may, you know, decrease that fear. But that's the main fear that I think I have is, oh, when I go out there, do I know everything that I need to know to be able to help the patients that are coming to my office and, you know, that's why I don't believe at all that we millennials, we don't work as hard as the previous generation because, you know, all the time in mind is how can I learn more in the time that I have to extend this training, I'll do it. But it's because right now there's so much information. There's so many things coming out that it's exciting, but it's overwhelming, you know. It's definitely, there's a lot. I mean, there's a reason we're all in cardiovascular medicine, right? It's exciting. There's a lot of subspecialty training. You cover all aspects of medicine. But it also, I have to admit, you made me a little nervous about, that's why some people do more training because all I keep thinking is the previous conversation about we need general cardiologists, right? There's so many patients that don't have doctors and can't be seen. And at some point, you know, you guys add so much value, you know, without all that extra training, right? That extra training obviously is amazing. And obviously it's professional development for you guys and very, you know, allows you to grow professionally in other ways. But you guys also bring value just at that general cardiology level, right? So there is the good and the bad, right? As an administrator, I'm like, oh my God, there's still nobody to hire, right? And then at the same time, the subspecialty training is amazing too. It's what differentiates different programs, right? Are the people who have all this extra training. I have to, so I know we're running out of time, although, and I need to ask you guys about unionization. This is obviously a hot topic across the country, right? Not just for fellowship and residencies, but also even primary care, right? Are moving towards unionization. And obviously this is everything we've been against and have never practiced this way. So what do you guys think of that? Is this a good movement or a bad movement? What do you think? It's a hard one, right? It's a hard one. I don't feel strongly one way or the other. I'm not in the thick of it at the moment. I certainly think we need advocacy from a position standpoint to speak for us in terms of our views or our value. And sometimes that can be done independently, but sometimes it requires unionization for the leadership to be there. Sometimes it requires unionization for the leadership to hear us. And so I think this answer is gonna vary depending on which institution you are at and how receptive your leadership is to hearing you. If you're somewhere where they are receptive and say, hey, look, I hear your point, I can't do this now, but give me a couple of years, we'll make it happen. That's more reasonable than this is never gonna happen. And so I think the answer kind of varies depending on which institution practice you are at and how necessary unionization is. I mean, I think it is born out of need. We didn't become physicians to unionize, but at some point we do want to be valued. And so if there's a need for it, then I think it's appropriate. But that's what I think about it. Yeah, no, I think same. I have been lucky enough that I haven't been put in an institution that I feel that this is a day-to-day need or want. Right now I'm in the system part of Mayo Clinic. I feel like there is a very open conversations to see how to improve every day. And this hasn't been a need or something that I felt deeply about, but there's definitely other places where when you have to, you have to, right? You have to advocate for yourself. But this, I mean, you just putting this into a bigger picture more than unionization is advocacy. So I am part of advocacy and then within the ACC, within the chapter to be able to learn how to be able to advocate for my patients and for the physicians too, in terms of policy, in terms of what's happening in the legislature. And it's been an interest of mine now, finishing fellowship because of my leadership position within the chapter to learn how to do this better as I transitioned to an early career, because I realized that if you don't sit at the table, then you're eaten by everybody else. And then if you don't advocate about what's fair for not only the patients, but also for the physicians, then you're left at the mercy of everybody else. And we're burnt out, we train a lot. As we're speaking about cardiology versus specialty training, that just means there is people that out there that have been training for 15, 17 years of their lives. And to go out to a system where they think that, or the people think that we're just giving everything, where we have given our life to be able to get nice reimbursement and good quality of life. And if that comes from the outside, and when it comes from the inside, from your own mentors, attendants, whatever, or your community, then that's hurtful, right? So then you know what this is like. So why don't you help us be better in a bigger picture? And I think that comes to that question of whether we work harder or not than the others. I think the question really is, where is really the priority and where do you wanna put your money? If it was your kid, if it was your son or daughter, would you want them to just give their life completely and forget that you're a human being and not advocate for what balance means, and at the same time be able to provide what the patients need in terms of care, right? I feel obligated to say, I swear I didn't bring you on board because you're such an ACC advocate. Are you on their payroll, Carlos? Because I feel like I missed something. But no, I appreciate that you already value ACC and also have already tapped into all the different possibilities within ACC, right? As you know, MedAxium is owned by ACC, so they're our parent company, so I can't say anything bad about them. But no, not that I have anything bad to say, but it's nice, right? Already you recognize the value they bring into your professional life, right? So I appreciate that. I guess my last question to both of you guys, and as time is running short here, for some of our audience are folks who are looking to hire new faculty, very junior faculty. What is your message to them? Like how are they gonna capture you? How are they gonna be more competitive in their offers? To you, Carlos, what was the good and the bad of your offer and how do they see the deal? Because again, you want somebody to come and stay and grow and plant the seeds and get married and have children for you, Carlos, right? So that they're part of the community and part of the practice and stay. You want them to retain your folks. So what are they gonna do to convince you guys to come there? Go for it, Carlos. Okay, so I think for me, for me, it's gonna be more of looking into what the leadership philosophy and perspective is. And what I mean by that is, I've dedicated a lot of my training also to see what good leadership means. And if I see that somebody is just very fixated and this is the only thing that we want, you only need to do patient care, you only need to, if you don't do this, if you don't do this, if you don't need this amount of RVUs, then you're done. Versus they are able to identify strengths and weaknesses and be able to see how I can build that from that. And I can add something to the organization from a different perspective. That's gonna be the place that I go the most because for me, it's not right for money, right? Money is gonna be a big issue too. I don't wanna just get out of training and be earning only like $100,000 a year because why did I do all this, right? But it's gonna be a matter of seeing that I can, once I'm in the system, I can have conversations, even if everything is not perfect because nothing's gonna be perfect ever, I can have conversations with this leadership, I can negotiate, I can be able to see that I can have some part in what that means for me to be important in the practice and to grow in the practice. So that's gonna be more of my perspective. And of course, to be competitive in terms of the rest of the things that they're pretty much just checkpoints that is like residency or fellowship. Most are very standardized in a lot of things, but if I wanna match into a practice or a hospital system or a university program or whatever, that alliance to me is gonna be more of that. It's gonna be how can I see that I can align with leadership and be empowered to be able to put my little seed in there. And Tripti, what do you wish you had done? What was good? And what did you wish you would have negotiated differently? Yeah, so it's a good question. I think, we take for granted that each hospital system, there is a need that we're going to sort of provide for them in terms of taking care of patients, right? That's basic. But then there's like, what does the physician want? And I think I value institutions that allow for growth and maybe some flexibility in that area, depending on sort of what our growth chart looks like for the next five years. So somebody may want to develop in leadership, whether it's at the institutional level or at the national level. So what kind of mentoring programs do you have for us to get there? Are you going to give us some protected time every once in a while to go to conferences and build those skillsets? Do you support that? If somebody wants to do research, can you give them a little bit of time in their first year to write their grant and connect them to people within their institution to get that grant, to make that plan successful? Or if you want to have a family, then can you bunch up their inpatient time together and allow them to go on maternity leave without losing pay? And so at least here, they hired five attendings when my year and each of us have very different practice or clinical responsibilities, depending on what we kind of want to do. So we have two institutions, the main La Jolla campus and an offsite, and people can kind of choose where they want to work, depending on what they need from life. And so I think there's a huge amount of flexibility built in here to allow for us to continue to sort of keep working and sort of seeing patients and doing, you know, collaboratively doing what the institution needs to do, but also individually progressing growth-wise. And I think that's what brings fulfillment to a position is that sort of flexibility. Yeah, I appreciate, I mean, you guys have, it's a common thread, right? You guys are both looking, want, nurturing environments that are flexible. And in fairness, you guys don't have all the answers, right, out of fellowship, right? So you want to be able to grow. So that makes a lot of sense. I'm hoping the folks looking to recruit are hearing this loud and clear and are accommodating in those requests, right? But I feel like we're in good hands. The fellowship directors we spoke to last week were incredibly optimistic of fellows in the system. And you guys are, you know, a breath of fresh air too, to hear that it's not just about work-life balance, it's about the whole package. And it seems reasonable and fair. But I'm grateful to both of you for the time today. I know you guys are super busy. Thank you for the time. And good luck to both of you. Thanks for having us, Hannah. Appreciate it. Thank you. And nice seeing you again, Tripti. Thank you so much. Nice seeing you too.

cardiology

fellowship

clinical faculty

mentorship

generational shift

professional development

unionization

business side

leadership qualities