Changing the Narrative About a Career in Heart Failure

I was staffing a routine heart transplant clinic, or so I thought. My current patient was a man who had been referred to me five years prior and had subsequently undergone left ventricular assist device implantation and then heart transplantation at my center. We were catching up on recent developments when his wife excitedly told me they had just met his donor's family. She then graciously showed me a picture of the donor's mother leaning forward, her ear on my patient's chest wall, listening to the heartbeat of her deceased son. As these events unfolded in the exam room, my phone buzzed. I glanced down to see a message from another patient. He was texting me on the ninth anniversary of his resuscitated cardiac arrest, the initial presentation of a cardiomyopathy, to express gratitude for my care. Within a span of 10 minutes, the ordinary became the extraordinary. We, in the heart failure community, make decisions that forever change the lives of patients and their loved ones. What a privilege. If I could go back in time when I was a trainee and ask what I would want out of a career, what more could I have asked for? I find deep meaning in my work, remain intellectually stimulated, even after 25 years, and I enjoy the camaraderie of a multidisciplinary team of dedicated colleagues. A medical school applicant, during her interview this month, asked me for lessons I have learned from my career. I told her to find a specialty she enjoys as much as I enjoy mine. Trainees should be flocking to our dynamic field. Given my personal experiences, I struggle with the recent decline in the number of applicants to Advanced Heart Failure/Transplant Cardiology (AHFTC) fellowships, even though I recognize that career choices are influenced by uniquely individual factors, including personality traits and economic circumstances. The Heart Failure Society of America recently convened the AHFTC Fellowship Consensus Conference to identify solutions to reverse this trend.1Drazner MH Ambardekar AV Berlacher K Blumer V Chatur S Cheng R et al.the HFSA Advanced Heart Failure and Transplant Cardiology Fellowship Consensus Conference.J Card Fail. 2024; 30: 391-398Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Since then, two surveys, one disseminated via the American College of Cardiology Fellows In Training listserv2Gilbert O Patel P Ponir C Drazner MH Phillips A Ivanov A et al.Factors associated with interest in advanced heart failure and transplant cardiology fellowship: a national survey of cardiology fellows.JACC Heart Fail. 2024; 12: 412-414Crossref PubMed Scopus (2) Google Scholar and one by the Women in Transplant and Mechanical Circulatory Support group,3Hamad E Bhardwaj A Contreras J Hall S Perspective on AHFTC Specialty by women in heart transplant and MCS (WiTMCS).J Card Fail. 2024; 30: 111-114Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar found that both compensation and work/life balance were perceived to be less favorable with AHFTC than alternative career paths in cardiology. A prior International Society for Heart and Lung Transplantation survey of adult cardiologists found similar results.4Moayedi Y Hershman SG Ross HJ Khush KK Teuteberg JJ Perceived generational, geographic, and sex-based differences in choosing a career in advanced heart failure.Circ Heart Fail. 2019; 12e005754Crossref Scopus (11) Google Scholar In response to these perceptions, it is worthwhile to review available compensation data. In a 2023 MedAxiom survey, the median annual compensation ($575,000) of AHFTC cardiologists (n = 59) was 98% of general cardiologists, despite their far lower (68%) work relative value unit (wRVU) productivity.5MedAxiom 2023. Cardiovascular provider compensation & production survey. https://info.medaxiom.com/compsurvey. Accessed 2/5/2024.Google Scholar Limitations of these data include a small sample size, significant regional variability and potential response bias, with uncertain participation rates by faculty at traditional academic centers. Nonetheless, this survey demonstrated that, at least in these AHFTC respondents, the compensation for a wRVU was higher than that received by other cardiologists, and that AHFTC compensation can be quite high. To provide additional context, three recent surveys found that cardiologists' compensation, when aggregated as a group, was in the top 8,6Doximity 2023. Physician Compensation Report. https://press.doximity.com/reports/doximity-physician-compensation-report-2023.pdf. Accessed 2/5/2024.Google Scholar the top 37Koval ML. Medscape Cardiologist Compensation Report 2023. https://www.medscape.com/sites/public/physician-comp/2023. Accessed 2/5/2024.Google Scholar or the highest8Grey S. 20 highest-paying medical jobs in the U.S. https://www.forbes.com/advisor/education/healthcare/highest-paying-medical-jobs/. Accessed 2/5/2024.Google Scholar of medical specialties. Recognizing that we need more granular information, the available data suggest that AHFT cardiologists are compensated very well relative to many other physicians, a message not previously discussed widely in the narrative about our field. Regarding work/life imbalance, the care of patients with advanced heart failure is not contained to weekday daylight hours, often requires being at the bedside, and involves emotional investment that can impinge on personal time. Thresholds exist where the amount of work, no matter how meaningful, becomes unacceptable, with potential to negatively impact physical and mental health. In my household, we coined the phrase "the filet mignon effect" to acknowledge that there are limits, even with very enjoyable activities, after which they become unpleasant, such as what might occur late in a meal at an Argentinian steakhouse. This is also true of work. The heart failure community needs to define the appropriate amount of work for a full-time equivalent position and advocate for these guardrails to be in place for AHFT cardiologists. I also suggest that we change the narrative. Working harder does not mean less career satisfaction. As Dr. Lisa Rosenbaum recently described, well-being is not tightly coupled to work hours but, rather, to the degree of meaningful work.9Rosenbaum L Beyond moral injury: can we reclaim agency, belief, and joy in medicine?.N Engl J Med. 2024; (Online ahead of print)https://doi.org/10.1056/NEJMms2311042Crossref Scopus (1) Google Scholar And it is here that we shine. The extraordinary stories we experience routinely need to be told, so our trainees will see the lifelong professional satisfaction possible with a career in heart failure. MHD was supported by the James M. Wooten Chair in Cardiology at University of Texas Southwestern Medical Center.