6 Questions: What's It Like to Work in Cardiology?

By Hadiyah Brendel

Physician

Dr. Mark C. Haigney, Director of the Division of Cardiology/Director of Military Cardiovascular Outcomes Research (MiCOR), Department of Medicine, F. Hebert School of Medicine, Uniformed Services University (USU)

Dr. M. Alaric Franzos, Associate Professor of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University (USU)

Years in field

Haigney - 28 years

Franzos - 8 years as a Cardiologist, 19 years as a Physician, over 30 years as a Navy Officer, retired US Navy Captain

Special Interests

Haigney - My primary interest is in the cause of cardiac arrest in the young, whether due to a genetic condition, or the use of a drug, or supplement. I’m also interested in  electrophysiology, which relates to electrical problems in the heart. 

Franzos - Exertional collapse, particularly sudden cardiac death, artificial intelligence, leadership

Favorite Accolade

Haigney - Getting promoted to Associate Professor at USU. That gave me the freedom to continue pursuing a career in academic cardiology. I also received the teaching prize from the medical students twice; that certainly was very meaningful to me. 

Franzos - A small plaque in the form of a surfboard with the phrase: “When average performers have had enough for the day and call it quits, champions are usually just getting started. Discipline is the watchword of great performers. Discipline makes the difference between the good and the great. Semper Fi. You saved my life.”  It came from a patient of mine who I knew was in extremis [close to death] and I was treating him in Hawaii. It captures the essence of my motivation for medicine. 

Q. Why did you decide to specialize in Cardiology?

Dr. Mark Haigney, Director of the Division of Cardiology/
Director of Military Cardiovascular Outcomes Research
(MiCOR). (USU photo)

Haigney: Very early on in medical school, I met with a cardiologist who happened to be the father-in-law of a family friend. That’s how I got introduced to Dr. Gottlieb Freisinger. He told me about this phenomenon of sudden cardiac death. I remember thinking, ‘That's pretty traumatic. Maybe that’s something that I should study.’ I did some cardiology research as a medical student and cardiology was always on my mind. Although, I also considered pulmonary medicine. I was impressed by how good the pulmonary physicians were at making diagnoses and general clinical judgment. 

As an intern though, I spent a month in the intensive care unit. Two weeks in the cardiac side, and two weeks in the medical intensive care unit side. That made up my mind. I felt the cardiac patients had a better chance of surviving and leaving the hospital in fairly good health. That certainly made an impression on me. You want to see your patients get better. The thing about heart disease is if it doesn’t kill you right away, usually we have very good treatments. It just becomes a question of identifying who’s at the highest need for those treatments.

Franzos: I was a navy pilot before I was a physician, so I have a lot of history in the service. But cardiology is an interesting specialty. Of course, the heart is fundamental to the practice. As I was going through medical school, it was fascinating to me how the heart as a pump worked. But then I began to appreciate that the heart also has a sophisticated electrical system. As I learned about those two very basics of the heart, they came together in something that was not only compelling but understandable to me. I was fortunate that I found both a passion and a clarity about the subject. That helped drive me forward. 

After I learned the basics and realized I was fascinated by cardiology specifically, my mother ended up having a heart attack in my fourth year of medical school.  She was hospitalized in a very severe condition. The school, [USU], was phenomenal and allowed me to do an elective rotation, away in my home town. That [way] I could be with my mom while she was being treated and in recovery. They set it up with a local physician to be my supervisor and the local physicians at the hospital welcomed me in and allowed me to participate in rounds with my mother. And seeing that compassion reflected back to me now, in the form of a family member of a patient, really helped shape the way that I treat my patients in the future. So, really particularly valuable. My mother ended up doing well. She had about a 20% chance of survival of one year. She ended up surviving another 10 or 12 years after that. So, really a great success story all around considering the nature of the tragedy. 

Q. What does a cardiologist do?

Haigney: Cardiologists see patients in clinic who have complaints due to their heart. And we perform a number of different tests. Cardiology requires you to know a number of techniques: ultrasound, angiography, measuring intra-cardiac electrical activity, nuclear scans, CT scans, MRIs. It's a specialty that has almost as much radiology within as it does clinical medicine. A typical military cardiologist has to be an expert in a range of techniques and imaging modalities. When they’re in clinic, they may be called to perform and interpret those various tasks. Certainly, they may be called to send a patient to cardiac surgery or to some other less invasive, but still interventional, procedure. 

I also attend in the Cardiogenetics Clinic, in the Walter Reed National Military Medical Center’s Pediatric Subspecialties Clinic. That clinic combines me with a geneticist, a genetics counselor, and a pediatric cardiologist. We see patients who have indications that they may have a genetic cardiac condition. We’re able to order genetic testing and give them an expert opinion on whether or not they have that condition. Then, we look at the family to see if anyone else in the family has the condition. Many of the patients we see in that clinic are very young, mostly active duty age and their families. 

Franzos: It’s a pretty broad field that deals with the health of the heart and the health of the blood vessels. And there’s subspecialties including interventional for opening clogged arteries, electrophysiology for pacemakers and defibrillators, and advanced heart failure and transplant. 

You might think, well that’s for old people, that doesn’t really apply to young troops. But in reality, for our young troops, heart-related and cardiovascular-related problems represent a significant amount of concern. In particular, in a deployed setting, heart issues are among the top five  reasons why people get removed from a deployed environment. And for 80% of those people who are evaluated back home, [they] are returned back into theater because their heart issues were resolved. Or [they] were not concerning enough, allowing them to go back to their combat position. So with all those heart issues impacting not only our older population but also our younger population, it clearly makes sense for cardiology to play a prominent role in military medicine. 

Q. What is one of the biggest challenges about working in this field?

Haigney: I had a challenging conversation with a patient we diagnosed with hypertrophic cardiomyopathy. Unfortunately, you can’t be an infantry soldier if you have advanced heart disease. From this patient’s perspective, they went from being perfectly healthy and happy to now having a potentially life-threatening condition that can affect their family. It’s very hard for people to hear that kind of news. It’s hard to give them that news. The tough part is when you identify a disease before it causes a problem, it can be hard for the patient to see that as good news, but it is far better than diagnosing a condition after it has killed the patient.

Franzos: The burden of illness that is a consequence of our collective lifestyle. It is a challenge to overcome the bad habits that are so tightly interwoven with our society. Food is central to our method of celebrating and is a great source of comfort. Unfortunately, many aspects of our diet are detrimental to cardiovascular health. So struggling to find a way to either overcome the determinants or help control consumption so that we minimize those determinants is a real challenge when so much of our societal nature and reward systems are built around food.

Q. What aspects of your job do you find most fulfilling?

Dr. Marc Alaric Franzos, associate professor of Medicine at USU's
School of Medicine. (Photo credit: Tom Balfour, USU)

Haigney: The other side of the coin is when we’re able to conclusively rule out a cardiovascular problem. In our genetics clinic, if we find someone in the family had a particular genetic change that caused them to have a disease, we then test the family. And if we find out that none of them carry that same gene, that can be very reassuring. That can be very gratifying. 

Then, there are cases where something bad happens but we have a very good treatment. One recent patient we saw passed out in a restaurant and turned out to have a very rapid arrhythmia, an arrhythmia that very easily could have killed them. But, they survived it. They’re going to get an implanted defibrillator which will prevent the same arrhythmia in the future. They’re very glad to be alive. And very grateful that we have the ability to give them protection so their family doesn’t have to worry. 

Franzos: As a cardiologist, we have the fantastic opportunity to intervene when people are at their lowest point health wise and oftentimes bring them out of a very dark pathway. Which allows them to reclaim not only extended life, but also an improved quality of life. So after they’ve developed a serious heart attack that’s resulted in heart failure, we can intervene and say there may already be damage done but we can help the heart heal. And it’s remarkable to see them recover. 

There are other elements, like if they’re exposed to toxins – alcohol, for example. People who consume a tremendous amount of alcohol can develop heart failure. I had a couple of [patients] who fell in this category. As we intervened and helped them understand that alcohol is a toxin causing their heart failure, they were able to recognize that and fortunately stop consumption altogether. In a matter of a little over a year, both of those [patients] were back up to full cardiac strength and were able to return to duties. So these are huge victories as a physician that we were able to capitalize on and share that victory with our patients. It’s tremendously satisfying. 

Q. In your medical studies, what prepared you the most for this profession?

Haigney: Almost everything you do as a doctor continues to prepare you to do a better job. Whether it’s your training before you leave your fellowship, or working with your colleagues, or attending conferences. Early in my career, one thing that set me up for success was teaching the medical students physical exam. Particularly, what’s called the auscultation of the heart. That’s using the stethoscope to listen for abnormal heart sounds and murmurs. This is a skill that is really hard to teach. And despite having four years of cardiology training, I still didn’t understand some of the nuances of cardiac auscultation. Teaching the medical students forced me to really learn it and has made me much more confident in my use of the physical exam. Pretty much everything you do in your field continues to reinforce the things you learn. But teaching is one of the most, I think, effective ways of improving your practice. If you can explain something to a first year medical student, it means you really understand it.

Franzos: A major aspect about our school – it has a tremendous humanitarian and compassionate aspect. I've seen so many other similar aspects where the school steps forward and takes care of the students when life happens. That’s a really valuable aspect to our school that may not be present in many other medical schools. 

The other aspect that is fantastic about USU is that we have a camaraderie that is unparalleled. That, in part, comes from the fact that we all know we are going to be serving together for the next decade. So if you will, there’s kind of emphasis that we have to get along. But there’s also a common goal in mind. And that’s that we’re all caring for the nation's war fighters ensuring that we’re allowing them to deploy and get into the fight when it’s needed. That common goal is also something that brings us together, very powerfully. 

There is a palpable commitment to that throughout the university. Everybody knows that we’re educating and training the professionals who are going to keep our warfighters healthy. That commitment is inculcated in our students and reflected back years later when we’re in those deployed environments, or in those overseas environments, or even consulting each other here in our CONUS hospitals, when we just pick up the baton and help the patient, and help our colleagues the best we can.

Q. What advice can you offer medical students considering this specialty?

Haigney: I recommend doing a cardiology rotation during fourth year as well as speaking with me, Dr. Franzos, Dr. [Robert] Goldstein, or other cardiologists as well. We have a lot of research projects going on. Learning about the research is a good way for a student to get a sense of whether the things that are being done in cardiology are interesting to them. 

Probably the most important thing is to remember to do an internal medicine residency. Internal medicine residency is a requirement for cardiology. It’s a very important discipline. It prepares you to think about disease in a more mechanistic way than if you would in surgery where you’re more interested in finding an anatomical problem and fixing it. The internal medicine residency also prepares you if you were to change your mind. You might decide while you’re doing residency that you actually don’t want to do cardiology, you want to do gastroenterology, or nephrology or infectious diseases. All those specialties, including endocrinology, hematology, oncology, require three years of internal medicine first. You don’t have to decide as a medical student that you want to do cardiology. It’s great if you’re interested, and we would love to have more medical students involved in research, but the time when you have to make your real decision is during your internal medicine residency. 

Franzos: My biggest advice is simply ask. Ask people you know, if they’re in medicine, if they’ve had prior military experience, and get their perspective. Don’t hesitate to ask the school directly. The admissions office, they’re very good at answering questions. Demystify the process and you’ll understand that practicing medicine in the military is just like practicing medicine anywhere else with just a little bit of extra icing on the cake as you learn how to address specific combat-related emergencies in case you’re ever called to do so. But generally, you’re practicing your specialty at the highest level with all the satisfaction that that contains.