Interventional Cardiology with Dr. Ali Haider

Virtual shadowing by med school coach brings you up close and personal with physicians from many different specialties. Walk through tough cases with each doctor and learn about their triumphs and the challenges that they face on a day-to-day basis. To view the video that this audio is from and to take the quiz that is associated with each podcast, visit shadowing.medschoolcoach.com. Today we're joined by a very special guest, Dr. Ali Haider, Dr. Haider's an interventional cardiologist and he's also very active on social media, especially on Instagram where he shares educational and interesting content. You can follow him at @yourheartdoc on Instagram. Dr. Haider, thank you so much for joining us today. Happy to be here. Thanks for having me. So the first question we'd like to ask you, which is something we ask all of the physicians who come onto the show is, what made you interested in medicine in the first place? Sure. So, for me, actually, my father was a doctor, he was a cardiologist. So I was, you know, like a lot of people out there who had parents who were in medicine I was exposed to a sort of a young age. You know, I was never told what to do. I was never pushed into the field of medicine, but obviously, by osmosis, you're around there. It's sort of, you know, it kind of builds and the interest builds. And you know, you go through this phase and I'm with this phase where I did not specifically want to be a doctor because I don't want to do what my dad was doing. So actually, when I was in college, I thought I wanted to go into business. I was originally going to major in the economics and these sorts of things. And then I realized that, you know, I actually like biology. I like the sciences and maybe there was some genetic component to it. I believe maybe there is some time. So, and then I found that I was just more enjoyable for me. And I, you know, I realized that I wanted to be able to work specifically with people, right? I wanted to do something where I can actually interact with people, have some sort of, you know, on a daily basis, have conversations rather than being on the phone and sitting in front of a computer screen. And I wanted to do something technical with my hands as well. And that's sort of what sparked my interest into and originally thought I wanted to do something like surgical field and then what I wanted into, you know, that route, that sort of made me decide, you know, what I think something in the field of medicine is what fits my mind is, you know, of course, my father was very happy. And I, I believe there was, you know, definitely some influences there that led me to my choice. Sure. So, one thing you mentioned as your father was a cardiologist. Was that influence into you going into cardiology? Also, very good question. So, when I decided I want to do medicine, I said, no, I don't want to do cardiology. You know, I actually thought I went through, I thought I wanted to be in T for a while. I don't even know why I decided that, I think. And then at one point, I was very serious about doing interventional radiology, right? Because I really like procedures, I like catheter based procedure. I thought it was really fascinating. I thought that was where the field of medicine was going, you know, smaller things, less invasive things. And I just thought the things that you can do with wires, catheters, blues was really amazing. And, you know, radiology portion, I just, I just like the, you know, the anatomy analysis looking at the imaging studies, the technology, but, you know, there was no patient contact at all. And then I realized, I was like, what is my dad doing just cardiology? This seems to be a mesh of all the, all the worlds together. So, you know, I, I found my route there, I think without just kind of defaulting through my dad did, but interestingly enough, it turned out to be exactly what I wanted. Right. So, beyond cardiology as a regular fellowship though, you went above and beyond and you became an interventional cardiologist, correct? What kind of drew you into advancing your training even further? Right. So, I mean, cardiology was awesome because, you know, you get to take care of patients with almost severely ill patients, you know, patients with heart disease, there's always going to be heart disease around. And I like the, you know, the fact that these are patients that you could see chronically and there was, you know, two facets of it, the very sick patients in the, in the hospital and then, you know, chronic patients, you get to see the relationships with. But, you know, interventional was awesome because number one, you get to do these procedures, right? And I want to do something procedural. And that's, to me, really, the, the real way you could actually save lives right in front of you. The patients are coming in half dead, sometimes dead, and you could literally bring them back to life. And I didn't think there was nothing more satisfying than being able to, you know, fix an impending death situation or someone with a, you know, a heart attack who was zero block artery in 20 minutes, we're able to make them all better. So that immediate satisfaction, the fast procedures, the innovation and the tech, you know, it was something that I knew that I had to do. And you might cover this in a little bit, but how much of your day is procedures and how much of it is spent like talking to patients, getting to know them and stuff? It's a great question and there's, it's a great question and there's a lot of variability there, right? So people who are interventional cardiology, there are people who are literally in the cat's lab doing procedures, you know, four and a half days a week. And then there are people who may go one day a week. So that's one thing I also liked about interventional cardiologies. You could still be a full-fledged, regular clinical cardiologist. So and I was looking for a little bit of a balance, right? I didn't want to only do cat's lab procedures. I wanted to be able to see office patients like build their relationships with my patients and be a full-faceted cardiologist, but focus on interventionals. So my schedule is I basically do office two, two and a half days a week, two to three days a week. And I do procedures in hospital duties, the other two to three days a week. So in some days, some weeks is more and vice versa, but that's the balance and that's, I think that's a very nice balance. And when I'm doing procedures, I'm busy, you know, I do a lot of procedures on those couple of days. I pack them in when I'm in the hospital, I like to stay busy. So that's, that's sort of my balance, but you could really spin it any way you like it in different, you know, different types of jobs will have different types of, you know, kind of a balance of the two. Right. Now, going back a little bit, when you were deciding on medicine in the first place and you were a college kid and, you know, you're, you need to hit all these pre-med requirements and apply to medical school, what are some of the challenges that you've faced during that process and how did you sort of overcome them in the process of applying to medical school? Because it's an incredibly competitive environment and, you know, even as a college student, you need to have good grades and do all these other things. So how did you handle that? Yeah. I mean, it's also a great question. You know, it's multi-faceted. No, number one, first of all, you have to do all these sort of pre-med requirements, right? So getting all those required classes means you're sort of, you know, you have to, most of the time, you got to have your major in some sort of sciences, right? I actually want it to be able to, you know, we're in college for four years. I'm like, I want to be able to take different types of classes and experiment and explore. And you felt like you sort of were stuck having to focus only on your pre-med classes plus all the core curriculum, you know? I was lucky enough to be in a college where there was not a strict core curriculum. So I was in mental liberal school and so that helped me. So I got all my pre-med classes out of the way. And I was, you know, I did my sort of biology major, but then I could do anything else I wanted on the side. And I think that's important. I think having that balance of an education is super important. And, you know, I don't think you need to be just 100% sciences all the time. So, to me, it was important to be able to do a little bit of other stuff, you know? And the other thing is, you know, there's a lot of resume ability that has to be done, right? You can't just take classes and do well. You need to be like, how do I make self-accompetitive candidate, right? So I actually, you know, I spent my summers, you know, taken extra classes. I did research over the summers and, you know, that's basically how I did it. I figured, look, you know, I would like to have my summers off during college. But, you know, three of my summers, I focused on just sort of, you know, at least at least half of it, trying to, you know, sort of alleviate some of the burdens during the school year with some of the classes I took and working on the research labs to sort of boost my application. So that's kind of the route I took, but I still was able to have one summer and then some half, you know, four or four to five weeks of the other summers to sort of relax. And, you know, I think you've got to find a way that works for you, but, you know, it's definitely competitive. So I don't know, even these days, it may be even more competitive. So you need to find a way to make yourself stand out, man. Right. Is there anything that you would tell your, your self, any advice you would have given to yourself knowing what you know now, you know, back to when you were going into medical school? It's a good question. You know, I took a year off after medical school, okay? Because I'm sorry, you're off after college before medical school. I did a year of research. Most of my vision was because I wanted to just have a break and not go straight. If I had to tell myself different, I don't take the break. I would have gone straight, you know, at the time, you're like, oh, I have so many years ahead of me. I want to break now when you're like an attending, you're like, man, every year counts. So I would tell myself, don't take the year off, apply directly to medical school, you know, because later on, you're going to want those years because training is long. It's a long process and you don't really count those years until you hit your thirties, you know? Right. Well, I mean, that's a great point. Training is long and actually the seven years it takes to become an interventional cardiologist after med school, at least seven years. You know, that could be a deterrent to some students. So what sort of advice do you have for people who are maybe in medical school or maybe looking at different fields and are thinking about how long training is going to be? You know, some fields may only require three or four years of training, but some require maybe seven or eight, so how does somebody balance that in their decision making process? I mean, it's an important thing to think about. I think we don't think about this enough when we're choosing our fields in medical school. I mean, you say, oh, this is five, this is seven years, but you need to factor in real life things. Number one, I mean, you know, what, um, you know, do you want to have a family, right? I mean, that's important, right? I mean, do you, you know, stuff getting married? You want to have kids? If that's going to happen, do you want to do training? And that's, it's an important thing a lot of us don't think about. Number two, I mean, um, uh, you have to think about what is it that you want? You know, and sometimes until you get through medical school, you go through your, you know, 30 or even your fourth year, you don't really figure out like what the bread and butter, what do these people do every day, right? A lot of people go to med school thinking about me doctor, but you may not know what goes on on a daily basis. Right? So what are you going to be doing every day of your life? So before you commit yourself to a seven year track, you've got to really ask yourself, like, and I, you know, just, you know, the idea of being a neurosurgeon or an intervention cardiologist may be cool, but what am I doing on a daily basis? Because in the end of the day, that's what's going to be important. So and, and I'm saying this because you want to be 100% committed to that path. You don't want to go down seven years and realize this is not what I want to do. And they're people who do that. They go into like, you know, I want to, I want to change gears and they, and they pivot to a different field. And that's, you know, it's not ideal because, you know, the years go by quickly. So, you know, I tell everyone, look, you know, shadow docs, you know, do some, you know, but there's virtual shadowing, we're shadowing trying to figure out what goes on on a daily basis before you commit yourself to that path because, you know, you're not going to want to change the course once you're deep into it. And I think that's a mistake a lot of people make is they don't do enough legwork or enough research or enough thinking about what a particular field really is. So, you know, it's, it's, it's, it can be a deterrent. And sometimes that's a good thing. You don't want to, if your second trip will quite people guessing yourself and maybe you need to look at other options because there's nothing wrong with that. To receive one hour of credit for the shadowing experience, take a brief five question quiz at shadowing.medschoolcoach.com. Pass the quiz and you'll receive a certificate of completion from med school coach. Now back to the show. Okay, so here's my presentation I have for you guys. So you want to do cardiology. So what I'm hoping to do here today is to give you a little bit of insight on how you get to become a cardiologist, what's the training involved, what's the various avenues you can take after you go into cardiology because this cardiology, but now this day and age, we're really compartmentalized and sub-specialized into numerous different facets of cardiology, which makes it so interesting and exciting and then maybe something for everybody there. So we'll talk a little bit about that. The training and the time of training involved. And a little bit of insight of what my job is like and then we're going to go over sort of a typical type of bread and butter case for someone in interventional cardiology like myself. So becoming a cardiologist. Well, first thing you got to know there is a lot of schooling and training involved, right? And there are some fields that require less training. Intermediate cardiology is just pretty much the same as becoming a neurosurgeon and there's a lot of training. So you obviously got your four years of undergraduate, you got your four years of medical school. There are seven year combined program options, which I had considered at one point in retrospect that wish I'd considered it strongly because like I told you earlier, every year accounts once you hit your 30s and 40s. Training. So three years of internal medicine residency, three years of cardiology fellowship. For the most part, there are some programs that have a sort of combined internal medicine fast-track cardiology where they do it in five years. It's not a lot, but there's some. There's also some of the opposite spectrum cardiology programs that have three years plus one or two research years. If you really want to go the intense research academic route, and so it really depends what you're looking for. After general cardiology training, then there's further sub-specialty training that can happen, which is one, the two, maybe even three years, depending on what you're looking for and what type of specific subspecialty you're interested in. And then there's also the option of research years that you can do. Some people tack on actually additional years in between residency and cardiology. For example, a lot, sometimes people don't match into cardiology, so they do some other ancillary cardiovascular imaging or echo some kind of training programs you can do before fellowship, actually. So there are options for that. So there are a lot of different ways to get to it. And of course, other extra years, a lot of people do a chief residence here, that acts on extra here. Doing the chief residence here definitely improves your, you know, your application, your chances, particularly if you're looking to stay at your own particular program to carry on. And again, we talked about the research years. And, you know, I took the research year between college and med school. Folks do do that, and you know, that's something to discuss with your college advisor if they feel your application could warrant it. Definitely one of the most competitive specialties. And we talked a little bit before. A lot of things that do matter, obviously medical school and your scores are very important. The residency program you go to is important. We recently scores, although this day and age now we have a pass fail for you, similarly one step one. So things are changing a little bit there. Research experience and the letter of Rex, perhaps even more important now with the pass fail of USMLE. So, and this is always a moving target. And this is just a small snapshot. There's a ton of other things in ways to sort of help improve your chances of getting into a cardiology fellowship. So talk a little bit about cardiology subspecialties and training involved. So we talked a little about the cardiology fellowship, right? So that's three years in general, okay? A lot of people, I don't know the exact numbers. How many people actually go into subspecialty? It definitely varies by year to year. International cardiology, clearly one of the more popular and it's probably the most common subspecialty in cardiology that people choose. In general, bread and butter, international cardiology is one year. And sometimes extra training for an additional one year, if you want to do more advanced training. So, you know, when I was there, there was just international cardiology. Now they're having more accredited programs for additional training, structural interventions. So I'll talk a little bit about that later and peripheral vascular procedures as well. So there are various models of additional training that can occur. Then there's the second most popular subspecialty is electrophysiology, right? So, you know, interventionals where the where the plumbers of the heart, the electricians are obviously, the electrophysiology is rather like the electricians of the heart. That is now used to be one or two years. Now it's pretty much around the board two years. So you're looking at two years of training if you want to do electrophysiology. What's becoming more and more popular also these days is advanced heart failure and transplant, right? So those are, and we'll talk a little bit about what they do. And most of those programs are also one year. And then advanced imaging specialists with the advent of more usage of cardiac MRI. We're seeing a lot more of these trainings pop up as well. So that's also an additional year for cardio advanced imaging. And then there's other niche specialties. Some of these have not all of them have accredited training programs, but you can find some non accredited ones for more niche training that can include anything from adult congenital heart disease, cardiocritical care, which is a lot of people have been combining cardiology fellowship with a critical care fellowship. And there's actually like an additional training after cardiology did you critical care. Cardio oncology is also becoming you know buzzword these days sports cardiology. This is just a name of few. And there's even sub specialty things that people just programs make up on their own and train people. And so you can really sometimes find a really innovative and you know types of initiatives of sub specialties if you look around for it. Are there any of those that you consider doing other than interventional cardiology? I think and I'm going to talk a little more detail about some of them, but I think interventional that I was going to do personally you said. Yes. Good question. You know, I probably would not have I really like electrophysiology. I like the diagnostic portion electrophysiology is awesome. The devices are cool. They're the ablation procedures. I just never really liked them. It's different type of personality, different type of understanding. They're like really smart. I mean, that's like a they're like totally different field of cardiology. Anyone else and they have to understand these lips and beeps that I can sometimes not understand, you know, they're so they're pretty smart. So to me, they're a completely different field, but for myself, I thought it was either interventional or just general non-invasive cardiology. Got you. So let's talk a little bit about what some of these most common versions of cardiology are. So non-invasive cardiology or general cardiology, right? So this is sort of the bread and butter cardiology. You finish your three years of fellowship and this is basically what what you come out with. So again, there's a lot of variations of this and I'm just giving you a little snapshot of how you can model it. Of course, there's the office based cardiology, right? So this is basically and some some cardiologists purely do office based, right? There are programs like that. They don't even go into their hospital and you may be just an office cardiologist. Maybe you're seeing patients in the office and people see anywhere between 15 up to 40 patients a day in the office. These are new patient hospitals, follow-up patients, and you're going to be managing these patients with medications or disease stays from heart failure, cornea disease, angina, things like that, atrial fibrillation, and sometimes you're going to be referring these patients to more specialized care if they need procedures and ordering various testing stress test echoes and these kind of things. So you're a diagnostician and you're treating them in various different medications in the office set. Then there's the inpatient side of it. Obviously in patient side is patients are a little bit sicker. These are patients who are admitted to the hospital and this is patient you're gonna be seeing in a consultative fashion, right? So you're being a patient admitted to the medicine floor and you're being called in as a consult for someone with chest pain or an arrhythmia or something that you're gonna help manage that patient in the inpatient floor as a consultant. Then there's a CCU side of it, the cardiac critical care unit, right? So the different hospitals have different setups for how all these things are done, but the critical care side is basically someone who's sick enough to be in the CCU. Generally, there's two ways that it happens. There's sometimes one doc who takes care of the entire CCU unit. And there's some models where different cardiologists will take care of their own patients in the CCU. So that's a little bit sicker patients and varies from patients who have just undergone a stent for an urgent heart attack to patients in severe cardiogen and shocks, severe heart failure and things like that. So that's kind of, to me, the inpatient side, the exciting part is the CCU because you really get to take care of the really sick patients and you can really, you know, you learn a lot and you get to do a lot on the inpatient side, especially with all the devices that we have these days and mechanical support devices, we can really do some amazing things in the CCU and even these are taking care of patients who are not even interventionless, just, you know, general cardiologists. So other things databases do reading studies, right? So this is also a lot of the bread and butter. This is what brings in the revenue for a lot of practices and this is, you know, the heart of the testing of non-basic testing of cardiology, okay? So we're talking about things like echocardiograms, which is basically ultrasounds of the heart, various types of stress tests, nuclear stress tests and other types of nuclear scans of the heart. They're different, you know, not just a nuclear stress test, you know, we're looking for coronary artery disease and blockages, but they're different type of nuclear stress test and sorry, nuclear scans that we do in cardiology looking for other things. Vascular studies, right? There is a lot of, you know, cardiovascular specialists, so there is a lot of overlap and what we do is cardiologists with a vascular disease, you know, like myself, for example, I do a lot of peripheral vascular work, where we overlap a lot with vascular surgeons, that often leads to a lot of turf wars, but there's also a lot of collaboration that occurs there. So, you know, we take care of patients with carotid disease, peripheral vascular disease, subclavian disease, venous disease and, you know, we do all, and for example, in our office, we do ultrasounds for all those disease states and we read those studies. Alter monitoring and loop recording, this is for patients with arrhythmias and palpitations and those sorts of things. So, you know, we're evaluating somebody with palpitations or in a particular arrhythmias, we do all kinds of heart monitoring. And now that whole realm is progressed a lot, you know, with the wearables, the Apple watches and the advanced and you have the tech with wearable devices. I think that's an area that you're gonna see a lot more buzz about and with these algorithms and these machine learning AI and this really fascinating stuff going on with wearable devices and EKG monitoring. So, really cool stuff coming out in the future pipeline, I think with AI is marrying with cardiac monitoring devices. So, and you know, this is a lot of people, you know, use their cardiology experience to go into, you know, entrepreneurial stuff and innovation. So, again, a lot of things that you can do with some of these things. Be on just clinical medicine. Other advanced studies also pet, not everybody does this, this is getting a little bit more niche, but pet scans, CT scans and cardiac MRIs. Again, these are imaging studies that even if you have not been an advanced fellowship, some people still do pet and CTs, sorry. MRIs is basically most of the time more advanced imaging folks. And most practices are a combination, right? I talk a little bit about my role. I do a little bit of interventional. I do a lot of non-invasive. I do most of these things aside from, you know, these advanced studies in my office setting. So, having that balance is kind of nice. So, that's non-invasive cardiology. Electrophysiology. So, now we're moving on to the electricians, right? So, these are the heart rhythm specialists. So, electrophysiology deals basically niched with any kind of heart rhythm disorders. And this can, you know, the most common thing is, for example, atrial fibrillation. That's, you know, getting a huge, and we're getting more and more patients, populations aging this ton of atrial fibrillation out there. So they take care of those patients quite readily. Other types of arrhythmias as well, such as SVT or superventricular tachycardia, WPW, ventricular tachycardia, there's a lot of arrhythmias out there that require treatment. And this can be from things such as medical therapy. There's a lot of advanced antirritmics. In short, in med school, we've learned these, and those are like always torture to figure out what's class as this antirritmic, what's the channel that it blocks. And, you know, electrophysiology are the experts in that. And of course, with all these cool advancements in a catheter-based therapist, it's really amazing what they could do. And they're basically putting catheters through various parts of the heart. They're mapping the signals of the heart, you know, kind of like you see on the top right here. These are, this is an example of an eighth ablation where they've mapped all the impulses of the heart. And they put burn marks to zap out the arrhythmia by creating these lines. You're really basically just char and lines into the atrium. And by doing things like that, they can eliminate arrhythmias. And this is showing just a snapshot on the bottom right of the type of intracardic arrhythmias. This is their version of an EKG. This may look all foreign to us. But you know, they're seeing things in kind of like matrix code when they're in there, you know. So other things that they do are device implants, right? So defibrillators and pacemakers, that's also a lot of the bread and butter of electrophysiologists. So patients who have, you know, slow heart rates or heart block, they're putting in various types of pacemakers. And patients who have cardiac arrest, ventricular tachycardia, or have severe heart failure to card them up. These, they put in preventative devices or ICDs or defibrillators, right? These defibrillators are implanted into their heart like a pacemaker and they're designed to protect you against rapid heart rhythms and cardiac arrest. And once these devices go in, the electrophysiologists are responsible for tweaking these. There's a lot of like programming and tinkering and you know, really they have to put on their sort of the engineer had to kind of, you know, figure out small, you know, nuances and how these things are programmed and a lot of computer stuff goes into it too. So not just putting the device in, it's really following these devices problem solving. It's really, really fun stuff when you get to learn about it. And if you like that kind of thing, you know, this could be good for you. Other things we talked about catheter relations, washman procedures, this is an overlap where you see with electrophysiology, interventional cardiology, washman procedures are where we're putting in a, a collusion of left atrial appendage, another way to manage atrial fibrillation to reduce your stroke risk. So this is just a little snapshot of what electrophysiologists do. Cardiovascular imaging specialist, so this is, I talked about before you're basically becoming a cardiac radiologist, right? So you're, again, you're going to be specialized in the bread and butter, which is nuclear cardiology, echocardiography, TE, which is transesophageal, echocardiography, right? Where we're putting the ultrasound probe down the esophagus to get better visualization of heart and various structures and valve disease and CTs. You know, so you know, this is just a little snapshot. This is an example of a coronary CTA. On the right, upper right, you have an example of what a 3D TE looks like. A TE guided structural procedure, a huge. So we have cardiovascular imaging, especially who are basically trained in invasive TE, meaning they, when we're doing things like microclips and watchman procedures, we really rely on our echocardiographers to guide us. So, you know, you're not just, an imager, you're working directly with the interventionalist and we're leaning on them to tell us, you know, are we in the right spot? Where should we go? So, you know, really to become an amazing collaboration when we're treating valve or heart disease and watchman procedures. So there's really cool stuff in the imaging space as well. And you get described into these cashlap procedures and you're just, if not more important than some of them. - Okay, of course. - And also like can someone go into this through the radiology route, or is it only through cardiology and then focusing more on imaging? - Great question. So there is a little bit of overlap. So with the radiology route, there are radiologists to specialize in cardiac imaging. And for those, basically, you're looking at nuclear medicine, nuclear cardiology testing, CAT scan at MRI. So they're not doing echoes or TEEs, but cardiac MRI, cardiac CT, and nuclear cardiology can be read by radiologists. And there's a lot of centers that have radiologists either sharing in that or owning that, you know that. But when it comes to TEE echo and all that sorts of stuff, that's all purely cardiology. - Gotcha. - But that's actually a very good question. And, you know, if you are interested in just doing it, purely imaging, then maybe the radiology, and in cardiovascular imaging, radiology route could be done. But, you know, if you're looking more than that, then cardiovascular imaging, maybe the way to go. But as you can see, even here in the intervention, there is a lot of overlap that occurs in some of these specialties. And, you know, as cardiologists, as you can see, as I'm talking about, we're putting a lot of different hats on from proceduralists, from clinicians, radiology, which is one of the cool things about cardiology, really fusing a lot of these modalities and subspecies together. Advanced heart failure, we talked a little about this before as well. So advanced heart failure doctors are medical doctors that take care of advanced heart failure and transplant patients, right? So it's their job to evaluate patients and figure out, okay, is this patient a candidate for something like a left ventricular assist device or maybe even a transplant, okay? And they're the ones who are gonna be managing those patients post-operatively. So they work really close with the, you know, transplant surgeons. They're very good at taking care of very advanced sick heart failure and cardiomyopathy patients, right? So we lean on this team of docs to help us with the very sick advanced patients. They're also, you know, they don't put in surgical LVADs or our transplants and they don't put in things like mechanical support, devices such as impella and ECMO devices, which are basically mechanical support devices that us as interventionals put it to support the heart and the heart is severely failing, whether it's a chronic problem or acute heart attack. And these doctors come in and help us manage those devices. And they help us, you know, segway the patient from, you know, getting out of the woods into a potential transplant situation. So we're sort of the plumbers we go, we stabilize them, they're really the smart guys who kind of help tweak them and get them out of the woods. So again, a real collaboration with the advanced heart fitter specialists and interventionalists and the acutely sick patients. And they focus also on the very chronically ill patients. So a very growing and important field. And we're going to see more and more of these folks out there. And some of these docs also do some procedures such as cardiac biopsies and right heart catheterizations or some procedures involved as well. But this is also, again, a very popular subspecialty of these days. And of course, the best interventional cardiology. And you know, as a lot of you guys know, we're basically talking about catheter based procedures. We're ways we can treat the heart with that open heart surgery, which started off in the old days with just coronary angiograms and coronary stenting. And now it's really blown up and we can treat all sorts of cardiac issues from bowel disease to autochromic and general heart disease to coronary disease with very advanced cardiovascular procedures. These are basically fluoroscopy guided procedures, right? So we got patients on the cath lab table with a live X-ray. And you can see an example of an angiogram here where we're injecting dye into the arteries. And you know, with wires, balloons, and stents, we're using live fluoroscopy to, you know, put wires and equipment down the arteries and treat blockages and other things such as that. And by that same technology, we're able to treat various valve diseases, micro valve disease, aortic valve disease, pulmonary, and tricuspid. We basically have technology to treat all four valves now. A further, you know, kind of giving more options for our patients and otherwise, but not at options. The coronary invention is definitely the bread and butter. So when you go into intervention cardiology, the first thing you learn is coronary disease. That's again, what all intervention cardiologists know how to do. And from there, if you want to further sub-specialize their different routes that you can go. And there are all kinds of fun tools, even just in the cornering around, you know, we talked about stents and balloons. Specialty balloons actually recently, just yesterday, was approved the coronary lithotripsy balloon, which is basically a balloon we're putting in the coronary artery for very calcified lesions. And it's emitting lithotripsy kind of like you treat with kidney stones that just got approved in the US yesterday. So we're excited to start use that. Just an example of all the awesome technology that's moving coming out there. And again, less and less bypassed. He's occurring because we have so many fun tools that we can treat patients with these days. And it's going to continue to advance. So then I put this on a different stride because it's basically becoming like its own sub-specialty now, interventional structural cardiology. So where interventional cardiology is the bread and butter of coronary structural is becoming its own center of sub-specialty. And this is basically treating valve disease, all right, congenital heart disease. And other things such as, you know, oops, other things such as the watchman device for left-atrial appendage occlusion. The biggest thing in in in structural heart disease, of course, is taver or trans-cafter aeroclassical replacements. This was probably one of the biggest innovations in medicine in the past 10 years, if not just cardiology, where we're, you know, have technology to treat the erotic valve by, you know, percutaneously, by a tube up the groin, up and replacing the the heart valve without any incisions. You know, patients can go home, you know, the next day, if not the same day with these procedures, and it's really revolutionized how we treat heart valve disease. Micro disease, again, on the top left, this is a picture of a microclip. This is a percutaneous clip that we place on micro valve for patients who have micro valve regurgitation. You know, obviously, the only way to treat that previously was open heart surgery to repair the valve. Now we can put these little clips in there to clip the valve to prevent the leakage. And this is done by going up to the right side of the heart, piercing across the septum to the left side of the heart to access the micro valve. And here is an example of the watchman device. This is what I was stuck doing all day today. This is when we're putting a little plug into the left-atrial appendage. This is for patients with atrial fibrillation who need to be on blood thinners to reduce the risk of stroke. And that's because this little appendage here forms blood clots. And you know, of course, if you're using blood thinners, just to kind of treat this one little area in the heart, people bleed all the time. So now we have these little devices where we can again go up the right side of the heart, we pierce across the septum, and we plug up that little spot there, including it, and separating it from the body. Therefore, patients can come off blood thinners because if you form clots in here, it can no longer enter the heart. So again, it's really cool stuff that we get to do. Purple vascular interventions. Also, this is something that we do, this is in our realm. So just like you have blockages in the heart, you can blockages in the arteries of the legs. Again, this is something you see a lot in smokers and diabetes. Leg blockages in the iliac arteries, the femoral arteries, and tibial arteries. Also, subclaving arteries in the carotid arteries. All these arteries can have blockages. All these can be treated with percutaneous measures and stents in the right scenario. Let's see, there's still a role for surgery here. But, you know, we have similar skills. I mean, if we could put in the stents in a moving heart, when putting a stent in a larger artery in the limb that's not moving, not that difficult. So very similar skill sets, you know, it's not really not that thankful, but you know what I mean. But really, similar skill sets and again, involves some additional training, but again, some cardiologists really specialize specifically in this particular knee. So a lot of avenues that you can go and lately, what we're seeing a lot of is invasive treatment of DVT in PE. The past, the only things to treat DVTs in submassive and massive PEs was, you know, either anicoagulation or sometimes trombolytics. Now we can put catheters in there and we can suck out cloths from the from the lung arteries. We can infuse trombolytics in there. And we find that this seems to be a very good procedure for subcentipatients and even DVTs, particularly young patients with big lead clots in the old days and even these days, a lot of people are just treating these with anicoagulation, but we can actually go in there, remove these clots and in the right patients, they can really improve quality of life. And again, this is this procedure is done by intervention radiologists, faster surgeons in some cases and cardiologists in a lot of cases. So again, a lot of overlap, like we talked about before, but this is just a little bit of a snapshot of some of the things beyond coronaries that we get to do in the world of intervention cardiology. Like I said, there's some people who focus literally on just the mitral nearby. Some people literally just do vascular, some people focus on venus. So you can really find what you love and what you like the most, or you can do a little bit of this and that, you know? So a lot of good options out there. A little bit about the types of jobs out there. Again, there's a lot of different types of jobs of cardiology. Again, just to break it down briefly, academic jobs, academic jobs, when we're talking about working at a large hospital under a teaching institution. Generally, these are more specialized in compartmentalized, meaning that you'll have that a non-invasive general cardiology docs doing their thing. The interventional doctors would specifically just focus on intervention teachers. Then you'll have one guy who's doing aerodic valve procedures. One guy may be doing the mitral valve procedure. So everyone has their specific nation. Maybe they have research interests in that specific niche. So they're becoming really sub-specialized, you know, thought leaders, experts in that particular niche. And there's also both clinical care involved in that and research involved that and sometimes as well as education. So those are sort of, you know, brief, brief, not still, what the academic job is. Then there's the clinical jobs where, you know, this can be private practice, this can be a hospital employee for a private hospital. They often do a mix of things, right? Where, you know, they're focusing mostly on taking care of the patients. They're not doing much research or education necessarily, but sometimes they do. And they're, you know, they may be doing a little bit of everything, okay? Then there's hybrid models. I'm more of a hybrid model. I'm a private practice employee, but, you know, I'm a, you know, I'm a professor. I have an academic title. I work at a teaching hospital. I do a lot of teaching. I do a little bit of research. So I like to do a little bit of a balance there. I didn't really like wanting to do, you know, you know, 20% of research, but I love education. So I want to focus on doing procedures, clinical care, and educating students, fellows, and that sort of thing. So that's the niche that I created for myself. And there's a lot of ways to go about that, depending on what you like to do, right? So again, I talked a little about this already, about what I do. Again, hybrid model between academic and private practice. I do interventional and structural procedures, which is my, what I, what I love to do as well as clinical cardiology. I never want to give up my clinic. My patients will kill me. I love my long-term patients. I love seeing my patients after I do a procedure, right? There's some interventionalists who, you know, they'll, urgent patient comes in, you know, they'll treat a patient who's having a stemmy or an acute heart attack, save their life. They'll never see him again. I like to see these patients in clinic. It's so satisfying to see someone who's on the table half dead. And I see them two years later and they're looking great. And I get to see them every six months and really build that bond. So for me, that satisfaction and that, you know, was more rewarding to me than just doing the procedures and working on our research, for example. And, you know, I split my time between office and procedures like we talked about and mixed in as other things that misfigure work, meetings, a lot of teaching sessions. And, you know, there's barely any time for meetings and lectures and that's due to early morning, late morning, and evening sessions and like we're doing here today. So, you know, you got to find time to get things in. And weekends always works too. So, but remember cardiology is not always every cardiology job is going to have weekend work to stay in dermatology and allergy. So, you know, people get sick on the weekends. So, you know, this is one of those positions where you're going to have to work weekends. But, you know, you can, it can depends on the situation you're in. You could be working every three weekends. You could be working every 10 weekends. So, you know, all there's a lot of wide range of types of jobs out there. And, you know, what you hear from one person does not apply to everything. So, you should remember that. If you really like the field, don't be dissuade necessarily by what one person is telling you about their lifestyle. So, there's different ways to approach it. Okay. So, that's my nutshell before I was going to jump into a case. Do you guys have any questions or I'm excited to hear the case. Thank you for sharing all those different things about different sort of specialties within cardiology. That was really, really educational. Great. All right. So, we're going to jump into a case. Cardiology case. This is trying to create to you sort of a bread and butter, interventional cardiology case. The 65-year-old male with acute chest pain. All right. So, 65-year-old female smoker coming in with chest pain and epicastric pain. And I'm going to try to walk you through like, you know, when I get involved the situation from the point where the patient comes in, what the top process is and how we lead from point A to point B. So, 65-year-old patient coming with chest pain and epicastric pain, right? So, obviously, as you learn in med school, the most important thing is always the history, right? Before you get anything else, you're going to have just a patient in front of you. You're not going to have labs, imaging studies. So, history is where all the action is at. And this is kind of what I, all my patients to the day, I still kind of about these issues when I'm going over my history. Timing number one, right? That's about the timing of the pain. Three episodes of chest pain, non-exercional, 10 minutes each, and now with ongoing pain, right? So, this alone, this line already tells me my differential in my head is already listed. I already have a sense of what's going on. Asking the right pin questions, boom, this gives you almost everything you need to know. Quality, epicastric, low chest burning, okay? Radiation, it's going to the left shoulder, and associated features not. So, this is, you know, in a nutshell, this is what you want to extrapolate from a chest pain history. And if someone who's very sick, you want to be able to do that pretty quickly, and usually you can get this information in about a minute or so. Paths medical history and the patient had dyslipidemia. This patient also had a significant family history. Her father had a myocardial fortunate age of 40, and she was also a history of smoking, packing a smoke over 20 years in occasional alcohol. For you, the system is positive for fatigue, and some mild play can, nothing pertinent really. Physical exam, blood pressure was 129 or 75 with a heart rate of 70 in respiration of 14. So, pretty much, normal looking for vital signs here. In general, she was relatively non-toxic, but in mild distress, you could tell she was comfortable. She had some diiferesis subtly on her skin. A long exam was clear. A cardiovascular exam showed flat neck faints. There was no heart murmurs. There was no edema. There was no other signs of abnormalities. And her abdominal exam was benign. So, after that, we were able to quickly get an EKG in the emergency room. So, here's your EKG. All right. So, I don't know how much experience y'all guys have of EKGs. If you follow my Instagram, hopefully, you know, a little bit. But here we'll walk through this. So, this is, you know, for my eyes, I can look at this in one second and tell you what's going on. A few things going on over here. Okay. We will go over some of the silly points. Let's see if I put in my little markers here. Can you guys see what's going on? No, I'll take a stab. Anyone? I don't see the markers, but I can tell what's going on. I didn't split the screen yet. So, okay. I see something that's concerning. Excellent assessment. Very descriptive, Dan. Yeah. I see ST elevations in 2, 3 and ABF. Very good. Very good. Exactly right. You've pointed out 2, 3 and F ST elevations. So, right here, we have ST elevations in 2, 3 and F, about 2 to 3 millimeters in lead 2, about 4 millimeters, 4 to 5 millimeters in lead 3 and F. And these are sort of convex ST elevations. And what you also see here are our reciprocal ST depressions lead 1 and L, okay. You also see some T wave abnormalities and V5 and V6. So, the diagnosis here is an acute inferior ST elevation microinfarction. So, we have our diagnosis. And if you remember the history that we had before, no big surprise here based on our history. What are our next steps? This is our diagnosis. So, well, if you're in the emergency room, you're basically going to page international cardiology. But before that, what are we going to do? So, if you have a stemming, and if you, you know, at the moment here, when you're in clinical, all the pathophysiology, all the pharmacology, everything you probably learn is like way back in your brain, right? But, you know, we know that a acute ST elevation microinfarction is called by a plaque rupture in the coronary artery thrombus formation. So, we want to use medications that's going to attack that angry plaque that's ruptured in her right cornea, presumably, and the thrombus formation. So, we're going to administer a bolus of IV heparin, right? IV heparin, which is going to target that acute fresh thrombus and help prevent propagation of that thrombus. We're going to obviously give aspirin, right? At the therapy with aspirin, we're going to give ticagolore, which, you know, you can give various, if, you know, you can give clopeter grill, but up these days, we're giving more ticagolore, which is a P2Y to platelet inhibitor, because we want to get those platelets inhibited. So, IV heparin is inhibiting the coagulation cascade and ticagolore is going to be inhibiting the platelets, right? Because no matter what we do, when we go procedurally, if we don't inhibit that clot and that plateletment in that plaque, that's rupturing, but we're not going to have a good outcome. In IV, morphine of the patient is uncomfortable. You can give that, but, you know, those first two medicines is what really is treating the pathophysiology of what's going on here. And, of course, that page of intermingial cardiology, and hopefully I can zoom over there in time to figure out what we're going to do next. When I get there as a cardiologist, again, we're going to kind of go over, again, the brief history, some other things to think about in situations like this, alternative diagnosis, right? For example, an aerodynamic dissection, there have been cases where something like an aerodynamic dissection has presented with an acute inferior stemmy. So, I always like to check pressures on both arms, always think of other things that are maybe going on. Confirm allergies always very important. Medication substance use, right? If this was maybe a 28 or 30-year-old person with not any medical history, you want to make sure they're not having any cocaine use because this could impact medications and treatment. Brief physical exam always put your stuff to scope on the patient. Is there a crackles? Is there any signs of congestive heart failure? Is there any heart murmur to worry about because there are mechanical complications that can occur? And other bad things that someone who's having acute heart attack can write, right? So, now that we know the diagnosis of the stemmy, we want to double back and make sure, okay, let's make sure there's nothing else going on here that may change what we want to do. We don't want to miss, for example, a papillary muscle rupture or an acute metrical step-told defect that would impact what we do and how we proceed. So, and I was, yeah, my fellows, when they bring up a case to the cath lab and they haven't examined them, and you know, you always got to remember the basics in medicine, right? And any other testing, for example, focused, everything's big and focused, these days. I'm curious, in med school, are they talking about focus with you guys in med school or training at all or? Not that much in med school, though, there are elective rotations you could do, but a lot in residency is sort of starting to switch over to training and focus. Yeah, ultrasound is getting better. So, sometimes throwing an ultrasound probe, and now we have handheld ultrasound probes that can really be useful, and I can give us some quick information. For me, taking something that a cath lab, knowing the left ventricular function, the heart muscle is fully important. And then activate the cath lab, and that's when the fun stuff begins, right? So, cath lab is where we're going to treat this patient. So, the diagnosis is currently in inferior stemmy. We're presuming there's going to be an occlusion in whenever coronary arteries. So, what are we doing in the cath lab? Well, we use catheters, like we talked about before, to access the coronary arteries. We're going to be injecting contrast dye directly into those arteries. So, we'd snake catheter up the arm or the leg into the coronaries. We're going to inject contrast dye to diagnose the obstruction. Once we've diagnosed that there's truly an obstruction from that plaque rupture in a clot, we're going to utilize wires, balloons, and stents to open up that artery. Basically, we're doing a plumbing job on the artery, right? And it's a class one indication to take the patient directly into the cath lab. Now, there are some places that may not have a cath lab. If you're some rural area or some community hospital, you can't get to a cath lab, then you're going to administer thrombolytics. Thrombolytics are basically something like TNK, which is clot busting medicine, which is going to act directly on the thrombus to try to open it up by breaking up the clot, right? So, that's still a potentially feasible strategy in some places. So, how do we get access? I'm going to, this is a quick little video I posted recently, I'm just going to show you how relatively quickly we can access the artery, just people, you know, I take it for granted, how do you actually get into the heart? But basically, this is exactly how we get in there. Let's see if this has volume. Okay, first give some lead in we then palpate the pulse and use a 21 gauge needle to get archery access. We then insert a small micro wire through the needle, remove the needle, load a sheet onto the micro wire, push it through the skin and into the artery and remove the dilator. That's it. That's how we get it. So that basically looks really nice. Yeah. Well, probably this is a little sped up. This process will probably take me 30 seconds. Okay. Once you're in, this little hole is where you can sneak all our catheters and wires to get up through the heart. And from this point to actually getting our first picture of the corny artery, I would say probably about 60 seconds, okay, first comes so it's quick. So once we've got our catheter up, this is the catheter I've gone up to my sheath. I've engaged it into the right corny artery and I take a picture. So I've inject now I'm injecting dye into the artery and what am I seeing here? I'm seeing dye travel down, but right here, we're seeing get hung up, right? So right here is where that 100% blockage is where that plaque rupture has caused the clot. Okay. So right at the very end, right about here. So there's a big blood clot sitting right here, and that's what's causing the problem. So now we got a catheter here and through this tube, we're basically going to pass a wire. So here, I'll pause this. This is our wire that we've passed through and right here is our stent that's gone over the wire. And we're basically stenting across that blockage, okay? And afterwards, you can now see that dye that used to be hung up here is now filled completely to the artery. So we got in, we wired it, we sucked out the clot, we put the stent in and now we've restored normal flow to the artery and presumably the patient's ST elevations will come down. The chest pain will go away and they're all better. So in this particular case, going from getting that sheath in to this stage, it was probably about 16 minutes. So if you know what you're doing, you can do it pretty quickly, right? Wow. Here, duration of case, 30 minutes, total of case, in this case, 30 minutes, sorry. So yeah, so this is what's great about interventional, it's quick, it's immediate satisfaction both visually and from the patient. And it's fun, you know, you get to you get to work with your hands and do some fun stuff. So that was how we treated that patient afterwards, we do a repeat EKG, we do an echo cardigan to assess the left ventricular function. Medical therapy, again, that patient's going to be treated with aspirin, ticagular, statin and beta blockers and maybe eight inhibitors. And they're going to be modern in the CCU for one or two nights and then they'll go home in a couple of days. That's basically from skin to skin, your standard ST elevation my carletation from ER in this charge. That's basically how we treat care to patients. And, you know, my role is obviously doing the procedure, but I would see this patient subsequently as their cardiology and consultation, which is one of the things I like about as in the prior practice room, I would get the fall of this patient and I would normally rather than one patient in the procedure, punt it off to the next guy to take care of that patient subsequently, you know, so that's what I like. So that was the case. Now how long is that, how long is that stent going to last? Are they eventually going to have to come back in and get it replaced or how does that work? Good question. So, you know, original stents were bare metal, right? So bare metal stents meaning it was just piece of metal. And we found that there was a significant rate of renarring that occurred and not necessarily plaque build up a scar tissue is like your body's creating end up the little tissue growth inside of that stent. And we found there was a significant rate of that up to 20% of the time we saw tissue growth in the stent. Then we got drug-looting stents. Drug-looting stents is basically stents that are metal that's coated with chemotherapy agents. Really, pachotaxyl was the first agent that was in there and it's basically inhibiting tissue growth. So that prevents that narrowing to occur from the body. And now the rate of renarring these stents is very low since single digit percent range, assuming you have a good result, you have to make sure the stent is, you know, well sized, it has to be well opposed. You know, we use intravascular ultrasound where we put a catheter down into the, you know, I had a little picture here earlier, I'm just going to show you here. This is an example of an OCT image. So this is a laser that we put inside the artery. And we can see, you know, we're seeing two dimensional when we're doing our angio here, we're actually seeing inside the artery and getting an exact look of what the artery looks like. And we can see how the stent is fitted in there. And we can size our balloons, you know, which range from two to five millimeters appropriately. So we really have strategies to optimize our stent placement and the rate of renarring is very low these days because of that. So again, in a nutshell, in cardiology, other bonuses, amazing innovation that we talked about that and there's only more cool stuff coming out. There's going to be more advancements in how we treat patients with catheters. I think we got the best toys in Medtech advancements. We're taking over the role of many open heart surgeries, we're less and less open heart surgeries. You're happening. There are even surgeons that are actually training in intervention cardiology. We do work together with them in a lot of cases, such as TAVR. But there are some procedures that we do on our own. So, you know, the amount of open heart surgery is definitely going to be going down in the future. So that's something to think about as well. And again, the collaboration we have with our other subspecialties and surgeons is really awesome. All right. I didn't have time to put together a TAVR case, but I want to just, I threw in a couple of quick photos before we started here, so let me show you, because this is one of my favorite procedures to do as a TAVR procedure. This is how we can replace aerodynamic heart valves. All right. And this, again, I was mentioning before, which I think is one of the greatest innovations in medicine in the last 10 years. Basically, we're taking a heart valve, okay, what's crimped on a catheter, right? And we can get the small enough that we can insert it into the femal artery, right? If we can get the femal artery, which is somewhere down here, and we can put this tube up into the aorta. So this is up into the aorta here, and we basically get a wire. You can see this wire here, and it's crossing your aerodynamic valve right here. If you imagine this is your aerodynamic valve, this is your heart over here. This is our wire going across your aerodynamic valve. And we can track this valve up around the aortic arch, following the, basically up from the going. And I'm just pushing this with my hands, and I'm turning this knob to kind of flex it goes up and around the arch. And like this, we're going to cross the diseased valve, okay, just like that. And once we're there, we line it up. We have this catheter here where we can inject contrast dye. And we basically, now we rapidly paste the heart at 180 beats per minute, right? Because we don't want anything to move. So our goal is to drop the pressure to 50 or something like that. So when I inflate this, nothing moves, right? So this is a balloon mounted valve. So currently this valve is crimped on a balloon. And I'm going to rapidly paste the heart. That's why this right here, this is a little pacemaker here. This pacemaker is going to paste the heart. So everything stops. I'm basically trying to put the patient into VF more or less. And I'm going to take an injection with this to make sure I'm in the spot I want. And then you're going to see. As we inflate it. So I take my injection. Like where I am, balloon goes up, inflates it, crushes the old valve to the side, and we've just replaced your erotic valve. Right? Here you go. Incredible. And this is probably the favorite thing that I do in the cath lab. And this procedure, again, skin to skin, can be done in about 40 or 45 minutes. All right. And that's all I got for you today. I would rate it. Thank you so much. That was incredibly educational and interesting. And it's hard to watch this and not want to go into interventional cardiology, you know? I grow up, man, you know. And also, so for any student who's watching who may think that they want to go into cardiology or specifically interventional cardiology, even if they're a pre-med or a med student, what advice do you have right now? So number one, I would say because to get to interventional cardiology, you need to get into cardiology first of all, right? And to get to cardiology, you need to segue into med school and internal medicine. So number one, it's never too early to start building your application. So one of my recommendations is cardiologist love research, okay? So I highly recommend trying to get involved in some sort of research. And even if you can't find cardiology research, right? Again, I did hematology research when I was a pre-med, right? So, you know, call call people, email people if you're, you know, if you're, if you have access to, you know, folks who, if you're a pre-med or you're a med student, you know, you can find places to do some research, even if it's just for the summer. You know, find people who are doing a lot of publications. Sometimes you can just call them and say, you know, you'll do anything. You'll do a lit review. You'll help them, you know, you know, anything you can do to help on a project and get your name on a paper and try to segue into some projects. That is, I think, probably one of the most important things I can do. And ideally, do something you're interested in, right? If you can find something that interests you and, you know, it'll also help you learn about the research process. And a lot of people, you may not know, maybe the research is something you want to do and maybe it's something you not want to do. But regardless, that's something you definitely should get involved in. And if you, and this is med school level, we're looking at mostly pre-med school. If you're in med school, definitely try to link up with the cardiologist at who are your professors, your teachers, try to shout out, it's never too early to shout out, right? Shout out somebody and, you know, try to link up and build a relationship, find a mentor early. It's never too early to find a mentor. You should have several mentors. I know people say get a mentor. in multiple mentors. Try to link up with someone in the realm of cardiology, build a relationship with a show interest. People want to see you around. People want to see interest. The people, the students that I remember are the ones who make it a point to, you know, come up and say, hey, I want to watch a case or hey, can I help you with something? Oh, hey, do you have any projects for me? So repetition and getting involved in it's important because a lot of it's people who you know what letters you get as well as research. So you want to be involved in that earlier in the game. So that's my advice. I think mistakes a lot of people make, you know, you may not know what you want. And that's fine. That people wait too late until trying to get involved in some of these things. And that's fair. And I also want to make sure everyone follows you at your hard dark on Instagram. It's, it's awesome. You post all the time. And it's very educational. There you go, right there. There you go. Yeah, you should find me on Instagram, YouTube, Twitter. And if you want to message me email, I left my email there. I'm always happy to feel the new questions you guys may have. So yeah, I'm always happy to help. Thank you for listening to the virtual shadowing podcast powered by MedSchool Coach. Watch each physician present their cases along with fascinating images and visuals at shadowing.medschoolcoach.com. There you will also find a quiz that accompanies each specialty. [Music]