What You’ll Learn

An early-career cardiologist with a private urban practice discusses racism in healthcare, communicating with patients, and differences between private practice and hospital-based care delivery in his specialty.

Interviewee: I’ve been a cardiologist for four years following a five-year residency. Or, I’ve been practicing cardiology for nine years, four years as a specialist, and five years as a resident. I practice general cardiology. I’m trying to do some interventional cardiology sometimes, but most of the people, especially when dealing with catheters, prefer physicians with more years of experience than only four years. I’m trying to do it. I’m working hard for that.

VIVO: Are you in a hospital setting or elsewhere?

Interviewee: Both. I have my own practice, my own clinic, in San Francisco. We are enlarging into a medical center, but it’s not specialized into cardiology. But whenever we need some kind of hospitalization, especially when dealing with catheters, when dealing with catheters or infractions or heart attacks, something like that. You need a hospital to work in.

VIVO: When were you were inspired in healthcare?

Interviewee: Before being a doctor, I was volunteered into America Red Cross and saving people’s life was my cause, and it’s until now. I’m fighting for this cause and I’m seeing a lot of racism when dealing within the healthcare services here in the US, especially when dealing with Black people maybe, Muslims, Arabs, Japanese, something like that. Anyone who is not a white American. I’m fighting for this cause, for myself. I’m trying to be as equitable as possible.

But you can say that medicine itself is racism. I’m going to explain that. Because Black people has a high risk for heart failure more than any other race in the world with 45%. It’s not something like human act. It’s like how God builds us. When dealing with these people, you need to have some empathy. You need to make them recognize their condition. I can say that this is my cause. This is my inspiration, saving people and trying to fight racism into the healthcare services as possible.

VIVO: When is the last time something new inspired your day-to-day work?

Interviewee: We had a case within our clinic. I referred to the hospital. It’s for a child, he was four years old and he has an infant condition, which is a condition that he were born with. 99% of these childs are going to die.

The child was diagnosed in our clinic, then he was directly referred to the hospital that we are dealing with. Unfortunately he was with a doctor who mentioned that he’s going to die. “Whatever we are doing, he’s going to die.” And he says that in this way for his parent. The child was a Black child. It feels a lot of offensive for me and for the whole crew of the clinic, because all of us knows that this kid is going to die, but you should not say that.

You should do whatever you can. You should try to save him, even if you already know that he’s going to die. But you should do whatever you can. You should make all of your efforts. Because of this, you can say my last time within dealing within children was totally changed because most of the time, when dealing within children, teenagers, and young adults, the heart diseases are rare. They are really rare, especially when we’re talking about hypertension, about infractions, about heart attacks, arrhythmias, SVT, VT, whatever it was. Most of them are really current between ages between 45 until the death, we can say, until 85, maybe more. When dealing within children and adults and teenagers, most of the time we are not totally focused on the case itself because we believe that they are totally normal. The regular condition is that they are normal. Because of this accident I mentioned before, I’m now really concentrating on that, I’m really focusing within my practicing with children, adults, and teenagers.

VIVO: What would you say is maybe the most persistent challenge that you deal with as a cardiologist?

Interviewee: Being able to do catheter, whatever the condition is. As I mentioned before, it’s really hard to convince people to undergo a catheter because most of them, let’s say they are 50/50. 50% of the people believe that they don’t need the catheter. 50% of people dies before doing the catheter. I believe that this interventional practice is really essential, really important, and I need to be an expert within that.

The emergency one, because we have two kinds of catheters or interventional practice. One of them is emergency one where the patient is now undergoing the infraction and your catheter is a golden globe which going to save the patient. Totally is going to save him and most of the time it would take no complications at all after the catheter. And we have something that we call a chronic catheter where the patient has something like a hypertrophy in his left ventricular and his coronary arteries are getting a little bit, not enlarged. They are not that flexible. You need to do the catheter, but it’s chronic, it’s not that emergency.

VIVO: So is the more challenging one when you’re convincing people to wear it in case of an emergency or is it more so just in general getting people to actually use this?

Interviewee: I’m going to say there are three factors. The first one is convincing people as you say it. The second and the third one are related to me for myself, personal factors. The first one of those personal factors is being a professional within a catheter, talking about a technique. And the second one is the decision, the decision to make the patient undergo a catheter, even emergency one or chronic one.

VIVO: What do you think cardiology will look like 10 years from now?

Interviewee: I believe that artificial intelligence is going to interact and has a lot of actions within cardiology. I heard about experiments that are engaging the AI within the ECG. I believe that the ECG where we have the electrocardiogram, we have a lot of diseases that could be diagnosed by the ECG, especially arrhythmias and infractions, which we call stamy. I believe that you are familiar with that. They shown the AI a lot of ECGs, and they ask him to start diagnosing each one of them. And the AI was right within 70% of the ECGs. It’s shocking. I have never believed that before. And when dealing with an AI, you would never be accurate that this AI is accurate. You would never do that because it’s a computer at the end. But now they are trying to educate the AI so that they are raising this percentage from 70%, and the target now is 95%.

Always, there would be a wrong grade. There would be a failure. But if you have a 90% of accuracy for a computer, oh my gosh, this is amazing and it’s going to make the act of catheters or any other interventional cardiac practicing would be really fast.

VIVO: What, if anything, do you think is not being said in cardiology that needs to be said?

Interviewee: People’s awareness, I believe. Here in the US, I believe, and it’s a personal opinion. We are not really concentrating on that. We are not really put efforts on that. A lot of, not a lot. I believe that 99% of people are smoking, even they already know that this is going to make your heart fail and would have some ischemia, would have some infractions, et cetera, et cetera, et cetera. And for a secret, I’m a cardiologist and I smoke in the same time. It’s funny.

I believe that the awareness is really low. We should focus on that. Again, as I mentioned before, one of my difficulties within the interventional practice is convincing people that this catheter is really important. It’s really essential. It’s really hard to do that. I don’t know if you are a physician or not, but you’re going to understand my talking because it’s really hard to convince people within that because they believe that you would never need a catheter if you are not dead. They believe that doctors would never get them alive and save their lives using catheter. They believe that. I was really surprised within this, but it’s real, it’s a fact. I believe that this set is really missing within us in the US, the people awareness. And we’re not talking about all the cardiology. About all the medicine.

VIVO: Why did you become a cardiologist?

Interviewee: I love it. As I mentioned before, I love to save people’s lives. And this is the most dangerous and people-saving specialty we have in medicine. Because you have the time to do that. As I mentioned before, whenever we are doing a catheter, whenever we are applying streptomycin, any one of these, especially when we are solving issues like DVT, like ischemia, like heart attacks, et cetera, et cetera, et cetera. You are going to say your work’s results directly. Directly. Because you are saving people’s lives and this is the cause I live for.

VIVO: How many patients do you see a day?

Interviewee: I have never count them, but no less than 30. Combining between the hospital and the clinic in the same time.

VIVO: If you had to separate out of those at least 30 patients a day, what percentages would you say are fall into a low risk category, maybe a moderate risk category and high risk category?

Interviewee: Maybe we can separate the answer of this question between the clinic and the hospital.

VIVO: Sure.

Interviewee: When we are acting within the hospital, it’s let’s say 70% of the patients are in high risk and 30% of the patients are in moderate risk, there is no low risk in the hospital at all. And on the other hand, in the clinic, 70% of the patients have nothing at all. They are no risk at all. Not only low risk, 70% have no risk, 10% have low risk and 20% have moderate risk. We are in the middle. We have moderate risk in the hospital and the clinic, but most of the time it’s in the clinic, not in the hospital. Sorry, I was wrong. In the hospital, not in the clinic. 30% in the hospital.

VIVO: 30%, moderate in hospital. And 70% high.

Interviewee: Right.

VIVO: Can you tell me about your decision-making process in determining which treatment might be right for a specific patient? And if it’s easier to talk about an example of a patient, that works too.

Interviewee: I’m going to try to make it as simple as possible. Are you a physician?

VIVO : I’m not a physician, no.

Interviewee: We need some more explanation. When we are doing any clinical choices or decisions, we have a lot of factors around maybe seven or eight factors. And those or the essential ones of those is the patient’s history, the physical examination, the diagnostic tests, the current guidelines, and especially when dealing with cardiology, our guidelines are being updated each year by the American Heart Association or the American College of Cardiology. We have something like a trusted associations that we are getting our guidelines from.

So we mentioned the patient’s history, the examination, the tests, the guidelines. We have something related to the patient himself, the patient preferences. Sometimes we are having some collaborations, especially for me, I have only four years of experience as a specialized physician. I consult a lot of other healthcare professionals and not only specialists in cardiology, we are having some consultations from other primary care physicians and we have our own clinical experience as a really good factor and being up-to-date. And this is related to the guidelines as I mentioned before. A combination between all of these, especially the patient’s history and the examinations and the tests. Those are the most essential factors that are going to affect my decision.

VIVO: I’m sure in the settings that you’re in the environments, there’s a difference in how each cardiologist approaches their day to day. Can you maybe share any of the differences of colleagues who maybe have 15 or more years experience, it doesn’t have to be exact, but who have been in the field longer compared to your four years in the field?

Interviewee: The more years of experience a cardiologist have, the less diagnostic tests they are applying. Most of the time in our hospital, our chief, the head of the cardiology department is doing nothing but catheters. He’s doing nothing. He is doing no tests at all. Other physicians are doing all of this and they are providing him within the results. And he’s only doing the catheters. Here he is not doing any echograms these days, any stress tests, he is asking for no blood tests at all because now he can say he’s a really major senior within cardiology.

While on the other hand, people with a few experienced few years, maybe like me, I believe, are doing everything. You are doing the echo, you are doing the ultrasound, you are doing the stress test, you are asking for blood tests, you are doing everything just to make sure that you are diagnosing right. As I mentioned before, it’s a factor that’s affecting the decision we have, the years of experience. The more experience you have, the less tests you are going to ask for.

This is the major difference. Sometimes it is different between a physician and another physician based on his job title. As I mentioned before, our head of the department is only doing the catheters because he is the head of the department and he has 30 years of experience. He is like a god in the hospital. On the other hand, we are doing a lot of other medications. We are dealing with a lot of chronic diseases. Because the more years of experience you have, the less chronic diseases and conditions that you are dealing within, you are dealing more with emergency cases most of the time. They believe that this kind of chronic diseases could be fed to the less experienced doctors to be done within with them.

VIVO: Being in an urban setting in San Francisco, what unique challenges or advantages even do you experience based on your location?

Interviewee: I can say that bad lifestyles of people. There is a lot of pollution here in San Francisco. People are smoking to the death, they are drinking alcohol to the death. They are doing no physical routines at all. They are not exercising, they are eating a lot of fat, they are eating a lot of cholesterol, a lot of fast food, et cetera. We have more and more cardiology conditions here in San Francisco. But on the other hand, here, everything is available. Everything. Even the robotic catheters is available here in San Francisco. You have everything to diagnose, everything to interact, everything to treat. But on the other hand, you have tons of patients. And as I mentioned before, all of them are difficult patients because they have no awareness and they are really hard to be convinced.

VIVO: Do you think or can you provide examples of how this setting that you’re in influences clinical decisions or patient interactions? And you’ve touched on that some, but do any other examples come to mind?

Interviewee: Most of the time patients comes to the cardiology clinic just to make an ECG or an ultrasound. They come to you and they would never provide you with their symptom, their history. They are not doing any blood tests at all. They just want to have an ECG and an ultrasound because they believe that this is going to treat you, this is going to make you feel better because they don’t want to believe that they have a chronic condition. They don’t want to have this chronic medications for the whole of their life. This is really hard. This kind of patients are really hard even to examine because as I mentioned before, you could not have a really good story. You cannot not have their truth history. And especially when we are dealing with patients who are having CBDs, CBD products, or alcoholic patients, especially from other ethnics.

I remember we have an accident, we were dealing with a Muslim patient and I don’t know if I get it well, but it’s forbidden to drink alcohol within Islam. They would never provide us with honest feedback about their history or their lifestyle because of their ethnic beliefs. It’s really hard to do that within the urban. I can’t compare, I can’t compare with the suburban or the rural because I have never practiced there. I’m living all of my life here in San Francisco so it’s hard to compare. But I believe that here we have more patients and more hard to be convinced patients.

VIVO: What does a typical day looks like for you? And how do you handle stress?

Interviewee: Within cardiology, and I believe in the whole medicine, a lot of stress is applying on the physician because he should be, in emergency phase anytime. Because maybe your neighborhood needs you, maybe your neighbor or your sibling, whoever is it. Because you are a physician, because you are a doctor, and they believe that you should be ready whenever they call. This applies a lot of stress on us.

Talking about my daily routine, maybe if you are asking about that, I’m going to my own clinic, seeing my patients, doing some administrative work because I own the clinic. After that, I go to the hospital where I can see patients with high risk and moderate risk who are accepted within the hospital itself. I make sure from their blood tests, I make sure from their ECGs, I do them ultrasound daily, daily to see if we have anything changed within their ECG or their blood tests, et cetera, et cetera, et cetera. Then finally we have the catheter. If we have a chronic catheter, we are doing it after 02:00 PM. If we have an emergency catheter, we are making it directly, whatever we are doing. Even if I’m seeing a patient, I’m going to stop that and ask one of my colleagues to do it for me and then go to the emergency catheter.

VIVO: And how do you manage that stress that you mentioned?

Interviewee: It would never be managed at all. I have a lot of conflicts within my house, within my wife, with my children, because a lot of time and most of the time it’s really hard to see them. It’s really hard to play board games within them. It’s really hard to have the vacation for myself, especially from the hospital. We don’t have a lot of time for us. Even now I’m talking to you from my work. From my office, I’m not in the house. It’s really hard. And you would never get your balance at all.

VIVO: Can you describe for me maybe any significant lifestyle changes you’ve made throughout your career as a result of being a cardiologist?

Interviewee: I had my whole room and my whole office into the clinic itself because sometimes I even cannot go back to house. I can’t do that because sometimes it’s easily just to sleep in the clinic and wake up in the next day in the same clinic without any need for driving or something like that.

I put the children into a school that is near to my clinic. My wife is working with me, she’s a nurse, she’s working into the clinic. And we get her canceled from her contact from the hospital because she’s not going to make it. It’s really hard to work in the clinic, in a hospital and raising children in the same time. She canceled her job in the hospital, and she’s only working with me in the clinic, and this is maybe the longest period we are having a time with each other in the work.

But because she’s the wife of the owner, she has some privileges. She can get back to the school of our children, drive them back to home, make them dinner, make them lunch, et cetera. Doing their homeworks, et cetera, et cetera, et cetera. All of the family efforts is on my wife and I’m trying to do the right financial decisions if we can say it right.

VIVO: What are the misconceptions people have about heart health?

Interviewee: They believe that smoking would never hurt them, the same thing for alcohol. They believe that walking is a sport. It’s not a sport. They believe that any kind of a pain into their chest, it’s something from the cardiac, from the heart. Most of the time it’s not. It’s from the lungs and it’s from the wall of the chest. And let’s see, ECG and ultrasound is not a treatment, it’s a diagnostic test.

VIVO: What’s the single most important piece of advice you would give to patients regarding cardiac diseases?

Interviewee: I can say believe whatever your doctor is mentioning for you because he is only thinking about your health condition. And changing your lifestyles really matters.

Participant Profile:

• Male Cardiologist in San Francisco, California
• 4 years as a specialist, 5 years as a resident (9 years total practicing cardiology)
• Works in both private practice and hospital settings
• Practicing general cardiology with interest in interventional cardiology
• Currently expanding his clinic into a medical center