So You Want to Be A Cardiologist

Take Your Time

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I was a third-year medical student in 1971 when I wrote to John Naughton, MD, who was the Dean of Medicine at the University of Buffalo Medical School.  I was really into distance running and, during that third year, qualified for the 1972 Olympic marathon trials by running to and from my hospital rotations.  I wanted to combine my interests in athletics and cardiology, but there was no such thing as Sports Cardiology at that time.  So I wrote to Dr. Naughton to ask how I could develop a career in cardiology with an interest in exercise.  I wrote Dr. Naughton because he had developed the Naughton Exercise Stress Test Protocol. 

You should know about the Naughton Exercise Test Protocol if you are a clinician.  It starts at a low exercise level and increases the speed and grade slowly. Specifically, the Naughton starts with a 0% grade at 1 mph for 1 minute (min), increases to 2 mph for 2 mins and then maintains a 2 mph speed but increases the grade 3.5% every 2 mins for six stages. This allows frail patients to provide useful exercise results even if they have low exercise capacity. 

In contrast, the Bruce Protocol is very demanding.  It starts at 1.7 mph and a 10% grade and increases to 2.5 mph and a 12% incline after 3 minutes.  It gets progressively harder in big jumps after that.  The Bruce Protocol is the most frequently  used protocol because it’s quick.  The high baseline and rapid increases in speed and grade literally and figuratively finish the patient quickly so the lab can move onto the next patient.  I have written before about the superiority of exercise stress testing over pharmacological stress testing and on the importance of getting good exercise, physiological data.(1)  Unfortunately, that rapid increase in work rate does not provide much subtlety as to the patient's true exercise capacity, peak heart rate and other physiologic measurements in frail patients.  The speeds and grades used in the Bruce Protocol are rumored not to have been chosen for physiological reasons, but because they fit the gears for the motor that Bruce used in the treadmill.  I cannot confirm that, so it should remain a rumor.

At any rate, Dr. Naughton wrote me back.  To paraphrase his letter, he told me to be the best medical student I could be, then be the best internal resident I could be, get into the best cardiology fellowship I could get into, and only after I completed standard cardiology training should I try to be an exercise cardiologist.  He said that others would not take me seriously if I tried to be an exercise cardiologist too early.  That turned out to be sage advice, and I wrote Dr. Naughton about 20 years later to thank him for it, remembering that gratitude is often short lived.(2) 

I am writing about this because medical students and residents who want to go into cardiology often ask me for career advice.  Many tell me about all the cardiology rotations they have planned for their pre-cardiology fellowship years of training. 

I suggest a different approach.  If you are going to spend your career working in and learning a subspecialty, I think you should spend your pre-specialty training learning as much general medicine as you can.  Definitely, students and residents should spend some time in their proposed specialty to get a good letter of recommendation from someone in that specialty, but then they should be the best medical student and internal medicine resident they can be, and do their specialty training during specialty training.  For those who want to be cardiologists, rotations in pulmonary, renal, endocrine and critical care are very useful, but I have used even my OB-GYN training during my years of cardiology.  If I have learned anything in my 50+ years since graduating medical school, it is that you have a limited time to learn general medicine and that nothing you learn before specialty training is wasted.

1.    https://pauldthompsonmd.substack.com/p/say-no-to-drugs-for-cardiac-stress

2.    https://pauldthompsonmd.substack.com/p/gratitude-is-the-shortest-lived-human

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