By Payal Kohli, MD

Knee-deep into my echo month, I have completely moved into a cozy corner of the echo reading room, complete with my laptop, my Otto textbook and a latte—oh, the joys of echo! Although I am a permanent fixture in the room, everyday brings a new set of third- and fourth-year fellows who come in, sit down, and start fervently reading echos, ignoring interruptions and trying to cram as many as they can into their short 4-hour block. When there is more than one in the room, they always seem to be asking each other, “So, what’s your number?” Alarmed at first, I soon realized that they’re not talking about that number. Instead, they are trying to get the requisite numbers to obtain COCATS certifications for level 2 or 3.

I am quickly learning about the Core Cardiology Foundation Training Symposium (commonly referred to as COCATS), realizing that it will affect the entire trajectory of my third and fourth years. The ACCF regularly issues these guidelines and updates, which outline precisely what Accreditation Council for Graduate Medical Education (ACGME)–accredited cardiology fellowships are expected to do in order to train their fellows. This includes not only minimum months required, but also the minimum number of cases and procedures required to obtain certain “levels” in each subdiscipline of cardiology as well. The levels are graded from 1 to 3, with 1 being the necessary level for every cardiologist to become board-certified and 3 being needed to be branded a subspecialist in the field. For example, for diagnostic catheterization level 1, a minimum number of 100 procedures and a 4-month training period are necessary. On the other hand, to obtain level 3 for interventional cardiology, 550 cumulative procedures and 20 months of training are needed. With all this talk about numbers, I have started looking over the COCATS requirements myself in order to decide what “level” I want to obtain in each of the subspecialties of cardiology. Turns out it’s not so easy to decide!

This complex decision is comprised of many factors, many of which have no easy answers. First and most importantly are my interests. What do I like? Well, that’s an easy one to answer, right? Wrong! Turns out that what I “like” is a function not only of the subject matter, but also the teachers who teach them to us. I never dreamed I would like echo as much as I do, partly because I have found Dr. Elyse Foster, who is in charge of the echo lab at UCSF, to be a great mentor and role model for me and never lets the subject get dull. Luckily, I am finding the subject matter interesting as well, but that’s not always the case.

Secondly, we must recognize our own strengths and limitations. This is another difficult question to answer since what we like and what we are good at may not always be the same. I may love hemodynamics (and I do), but if I’m all thumbs in the cath lab, it really doesn’t make a lot of sense for me to get level 2 or 3 in interventional, does it?

Thirdly, in order to make this decision, we must have a clear career trajectory in our minds, something that is often hard at this stage of our careers. There’s no use trying to reach level 2 or 3 in electrophysiology if I eventually plan on becoming a vascular medicine specialist who will never put in a pacemaker or do an AFib ablation. The sooner we can try to crystallize which way our careers paths will go, the better we will be able to customize our training to fit this.

Even if you’re one of those people who knew the day that you were born that you wanted to be an interventionalist, these COCATS levels in other disciplines still apply to you. It seems that what you can do outside of your subspecialty becomes important when you are looking to be hired. In the ever-shrinking job market and dropping cath volumes, it might be good for you to get level 2 in echo in case you end up getting hired at a program that cannot support another full-time attending in the cath lab. That way you can read echos 1 or 2 days a week instead.

At many of the academic programs where we’re being trained, it is impossible to get maximum levels in every subspecialty within 3 or 4 years, which is something I’m really struggling with. For a long time, I worried that by not having level 2 or 3 in everything, I may be closing doors to jobs in the future. But, I have now realized that being forced to confront my interests early and decide what I am good at, what I like and what I want to do, I can actually tailor my training in a more enjoyable and rewarding way.

So, I have to ask… what’s your number?

Payal Kohli, MD, graduated from MIT and received her MD from Harvard Medical School. She completed her internal medicine residency at Brigham and Women’s Hospital in Boston and was a research fellow at the TIMI Study Group. Dr. Kohli began her clinical fellowship in June 2012 at the University of California, San Francisco.

Keywords: San Francisco, Cardiology, Schools, Medical, Internal Medicine, Reading

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