"To lead, gather all the information you need with your head, then make decisions equally with your heart."

Matthew W. Parker, MD, FACC, ACC Early Career Section imaging editor, talked with Prem Soman, MD, PhD, FACC, about building a successful career in cardiovascular imaging. Soman is the past president of the American Society of Nuclear Cardiology, associate professor of medicine (cardiology) and clinical and translational science, director of nuclear cardiology, director of the cardiac amyloidosis center, and director of advanced cardiac imaging fellowship at the University of Pittsburgh.

How did your career in cardiac imaging get started?

I started my career with medical school in India, and then moved to London where I trained in both clinical research and cardiology at the Northwick Park Hospital and Institute for Medical Research. Avijit Lahiri, MBBS, MSc, MRCP, FACC, and Roxy Senior, MD, DM, FRCP (London), FACC, were my mentors in nuclear cardiology and echocardiography.

Through them, my interest in cardiovascular imaging and imaging research began. Next, I moved to the U.S. and completed my training at Lehigh Valley Hospital and Tufts Medical Center with James Udelson, MD, FACC, and Natesa Pandian, MD, FACC.

My formal training as an imager was therefore in both nuclear cardiology and echocardiography, at the time when cardiac computed tomography and CMR were coming into their own. A question that came up to me then and still comes up now is, "How can you make an academic career out of those established techniques when new modalities are growing up?"

However, I think that being excited about your area of expertise is more important than what modality you specialize in. The drive to pursue excellence and enthusiasm to apply your skills to new opportunities can sustain a successful career in any modality. For that matter, there are experts in electrocardiography who are still innovating and improving the field.

How has your job description at University of Pittsburgh evolved over time?

In terms of job title, I started as director of nuclear research and then became director of nuclear cardiology, similar to the way many academic cardiologist-imagers step up from associate director to director of an imaging laboratory.

When I realized that we had a cadre of world-class advanced imagers at the University of Pittsburgh, I saw an opportunity to start an advanced imaging fellowship that has now trained about nine cardiologists in advanced imaging.

Similarly, when we started doing cardiac pyrophosphate scanning and many of the patients were positive for cardiac amyloidosis, I saw an opportunity for a Cardiac Amyloidosis Center that organizes clinical care, imaging, biobanking and translational research around these patients.

This has been an exciting way to make the most of an emerging imaging technique while expanding care for an underappreciated disease.

A lot of success is taking an opportunity and running with it. At first glance, an opportunity may not look like what you had in mind or may seem like a problem. I have found that building and creating programs to address those needs is very rewarding.

At the same time, all careers do not necessarily look alike. A common pathway – almost expected in many academic jobs – is to write papers and participate in studies, then write grants and lead studies.

There is a danger in following any traditional pathway too closely that you may not notice other kinds of work that you love, whether it is building programs, teaching or other aspects of cardiology.

You mention teaching fellows. What are some of the most common mistakes you see among fellows when they transition to their first jobs?

There is one big topic we should all talk about openly but do not. I call it, "The Standard Myth of the Job in Academic Cardiology: Pretend Not to Care About Salary."

Now, there is a realistic expectation for salary in academic cardiology that is different from clinical practice or industry work, but early career cardiologists should talk about salary openly. You can have all kinds of success, rapid promotions, publications and more.

However, if you feel that you are unable to do what you want for your family and provide a good quality of life, you are not going to be fulfilled yourself.

Or burn out from moonlighting!

That is right.

Starting out low eats at you and lingers in the back of your mind for your whole career. So, it is important to talk openly with your spouse about what your financial needs and expectations are, and be ready to discuss what is realistic. Protected time; allocation of time between clinic, research lab and administration; and various metrics and benchmarks are all equally important to salary.

Break the taboo and talk about it like you would the others. The notion that salary is something that academics should not talk about is counterproductive in the long run. Again, you must have realistic expectations!

I have heard you advise early career mentees to be wary of "director" titles. Why?

Titles can be an important sign of progress, both recognition and progression in your career. The title "Director of X" is naturally a part of many people's idea of success. The key is to make sure you want everything that comes with a particular title.

It can be useful to reflect on the types of activities that you do in your work: read or interpret imaging exams, teach, recruit for clinical trials, plan research projects, review quality, or review budgets and finances.

• Which of those things do you find yourself wanting to do more of?
• Which do you want to do less of?
• If reviewing a budget and letting someone from your lab go because of a financial problem is something you dread, are there enough alternative activities to offset that?
• Or would you be better off with a different job description involving more of something else?
• In other words, do the opportunities to grow and contribute add up to more than a nice item to list on your CV?

I do this whenever I am asked to chair a committee or take on a new role.

No job is all fun, but if you can find a job that is 70 – 80 percent aligned with your goals and vision for yourself, that is a great job!

While we are talking about titles, can we talk about what we call ourselves? Whether you talk about multimodality imaging or advanced cardiac imaging, we are cardiologists-imagers or imaging cardiologists, not just "noninvasive cardiologists."

As I wrote in an editorial for the Journal of Nuclear Cardiology, "noninvasive cardiologist" only means a subset of cardiologists who do not work in the cath lab, which fails to capture the time and effort spent developing expertise in cardiac imaging.

Moreover, a multimodality imager who can competently interpret three or four modalities, or an advanced imager who can organize a lab to perform cardiac imaging and knows how one modality complements the others, is not a generalist but a specialist, and we should identify ourselves that way.

What nonmedical skills have been most important for success?

Leadership skills are often formalized with certificates or degrees like an MBA, but leadership revolves around a genuine interest in other human beings. No training in marketing, finances, influence or management can replace the ability to sit down and talk with someone, and listen to what they have to say.

I have attended several leadership courses, including a "mini MBA" certificate program, and the objectivity and skills for collecting and measuring data that came with it are helpful.

When you make decisions that affect the people you work with, you need that objectivity to assemble all the relevant information in your head. Then you must make the decision equally with your heart.

I am glad that you mention the interpersonal dimension of leadership. Many early career professionals are anxious about giving bad news or critical feedback to colleagues. How do you approach that?

First, whether you realize this or not, people usually perceive when something is wrong or when they are not performing to their full potential. Second, I think of parenting as analogy: when bringing up kids, the parent enjoys time spent with the kids, tries to understand the kids as human beings, and naturally wants to be "buddies."

However, the parent also must demand excellence and enforce the rules strictly. When you genuinely care about people and understand what they are capable of, they know that, and you can push them toward excellence. Leadership is a privilege you earn in that way.