Cardiology

Section 1: Information about the writer

Hashim M S Hashim
ST4 Cardiology
Eastmidlands (Nottingham rotation)

Section 2: Scope of practice in the UK:

• Cardiology is one of the most popular medical specialties in the United Kingdom. There is a wide range of clinical activities in the care and management of patients with heart disease. It is a highly practical skill based medical specialty but other aspects such as cardiovascular clinical pharmacology, non-invasive imaging and evidence based medicine are equally important. It enjoys an unrivalled evidence base of effective preventive, diagnostic and therapeutic options.
• Cardiologists generally work as hospital based specialists looking after patient in coronary care units, cardiology wards, outpatient clinics, providing advice to other specialties, performing and reporting cardiac imaging tests and cardiac procedures.
  In small district hospitals they may work some of their time as part of acute medical admissions teams looking after emergency medical admissions admitted to acute medicine units. They look after patients presenting with Ischaemic heart disease, heart failure, arrhythmias, valvular disease, cardiomyopathies, congenital heart disease and other cardiac conditions.
• Cardiology has a strong multi-professional approach which means collaborative working with other medical specialties e.g. diabetes and renal physicians, cardiac surgeons, radiologists, specialist nurses, allied health professionals and primary care colleagues.
• Sub-specialisation within Cardiovascular medicine has become common place with individuals focussing the development of their expertise in areas such as cardiac imaging, coronary intervention, heart rhythm disorders, adult congenital heart disease or heart failure.
• There is a wide range of procedures that the cardiologist perform including coronary angiograms, coronary angioplasty, right heart catheters, permanent pacemaker insertion, Implantable cardiac defibrillator insertion, catheter ablation, transcutaneous aortic valve implantation, closure devices insertion and valvuloplasty.
• There is also a range of imaging modalities including transthoracic echocardiography, cardiac CT, Cardiac MRI, myocardium perfusion nuclear scans and transoesophageal echocardiography.
• A typical week timetable for a cardiology registrar in a district hospital will include 2 lab sessions, 1 echo session, 1- 2 clinics, 2-3 ward rounds, CCU cover and 1 administration session. (Each day is divided into 2 sessions: 09:00 – 13:00 and 13:00 – 17:00). On-calls in district general hospitals are usually medical registrar on-calls covering medical admissions and medical wards. In tertiary centres more time is designated to training in cath labs and imaging and on-calls are for cardiology only covering the CCU and cardiology wards in addition to the PPCI calls and doing emergency echocardiography.

Section 3: Type of Training/ Route to Training:

• Before applying to cardiology you need to have completed the 2 year foundation programme or equivalent and completed the 2 year core medical training or the 3 year acute care common stem training or equivalent.
• Cardiology training is a 5-6 year training programme starting at ST3 – ST7 (ST8 is optional for those who want to become cardiologists and General Internal medicine physicians). The programme is divided in to two phases; The first phase is the 3 year core cardiology training (ST3 – ST5) when the basics of general cardiology are learnt in addition to general internal medicine skills by doing general medicine on-calls.
• The second phase is the 2 year sub-specialty training when trainees focus their training on their chosen subspecialty for 2 years. If a trainee wants to have dual accreditation i.e. Cardiology and internal medicine they have the option of extending their training 1 extra year, ST8 and do 6 month of internal medicine and 6 month of cardiology.

Section 4: Sub-Specialties

Up until recently there were 5 distinct cardiology sub specialties:
1- Coronary intervention
2- Electrophysiology and devices
3- Heart failure
4- Imaging
5- Adult congenital heart disease
However, trainees now are given more flexibility in combining some of the specialties except for coronary intervention trainees and cardiac electrophysiology trainees who cannot combine their specialty with anything else.
On the new system a trainee must complete 4 units during ST6- ST7 (each unit is a 6 month block). The table below shows the subspecialties and units available:

Any subspecialty that is equal to 2 units can be combined with any other specialty that is also equal to 2 units to make a total of 4 units. For example Heart failure and devices or heart failure and Cardiac MRI or any other combination with a total of 4 units.

Section 5: Application Process:

• Recruitment to all medical specialties is organised by the joint royal college of physicians training board. They have a designated web site for applications to all medical ST3 level training programmes in the UK (www.st3recruitment.org.uk). This website contains all the details of the process of applying to all medical specialties at ST3 level including cardiology. On this website there is a link to the oriel application system (www.oriel.nhs.uk). You will need to register on the oriel application system and when the application period is open you can apply through this website and fill in the application form.
• Unlike all other medical specialties, applications to cardiology are open once a year in February and there is no round 2. The application is usually open for 3-4 weeks and once the application period ends, all the application forms are assessed and everyone who meets the eligibility criteria (see below) will have their application go to the next step. The process of assessing the application from against the eligibility criteria is called long listing and everyone who passes this early step is “long listed”.

Section 6: Requirements To Get Into Training (Person Specification):

• MBBS
• MRCPUK part 1 at the time of application
• MRCPUK full diploma by the time the job starts (usually the job starts in August).
• GMC full registration + licence to practice by the time the job starts in August.
• Successfully completed a foundation programme or equivalent foundation competencies.
• Successfully completed a core medical programme within the last 3 years or equivalent core medical competencies (alternative certificate signed by a consultant).
• At least 24 months experience in medical specialties i.e. core medical training or equivalent. (So you cannot work for 1 year and sign an alternative core medical competencies certificate, you have to work in medical specialties for 2 years).
• Eligible to work in the UK (From a visa and immigration point of view). Either British citizen, EU citizen, have indefinite leave to remain or on a TIER 2 visa and be on a training post when you apply. If you are on TIER 2 doing non-training post you can still apply but you will only be considered after the candidates listed above are offered jobs.
• Either the Undergraduate medical training was in English (most of us) or you will need IELTS 7.5 total score and 7.0 in each domain.
• Not been removed from the cardiology training programme in the past.

All longlisted applications will then be scored (see below) and everyone who scores high enough will be invited to attend the interview (this process is called shortlisting). The interview happens usually within 1 -2 months after the application period closes.

Section 7: Important CV/Portfolio Perks (How To Achieve Them):

Scoring of the application form:
There are 8 categories in the form that are scored. These are undergraduate degrees, addition achievements (prizes and distinctions), postgraduate degrees, MRCP UK, presentations, publications, teaching and Audit (now known as Quality improvement projects). I have copied the scoring system from the ST3 recruitment website below.

The maximum score is 78 and the average score for cardiology applicants is around 45. If you want to apply next February you should have a look at your CV today and score yourself. You should then identify the areas that you can increase your score on and start working on it between now and February. It is a big mistake is to open the application in February for the first time and only then realise that you do not have time to improve your score.

Section 8: The Interview:

– The interview in cardiology is divided into 3 stations. Each station lasts for 15 minutes and there are 5 minutes gaps between the stations. So the total time spent during the interview is 60 minutes.
– There will be 2 different interviewers in each station marking you. So overall there are 6 interviewers who are marking you on the day. In station 1 there is a third interviewer checking your documents and occasionally there might be extra interviewers or a lay man observing but all of them do not mark you.
– Each station is divided into 2 sections (details below). Each one of the interviewers will mark you out of 5 in each section. So interviewer 1 will give you a score out of 5 in section 1 and a score out of 5 in section 2 of the station. Interviewer 2 will also give you a mark out of 5 in section 1 and a mark out of 5 in section 2. So for each station you will be given a mark out of 10 for section 1 (5 from each interviewer) and another mark out of 10 for section 2 (5 from each interviewer). This will be clearer on the details below.
–
Mark Rating Assessment

Station 1:

•  The two areas of candidature assessed here will be your suitability for/commitment to ST3 cardiology and your application and evidence of your career to date.
• You will be asked to bring a folder that contains all the documents that support your claims on the application form. This is called the “evidence folder” and will be checked by a third interviewer during station. This third interviewer will not give you a mark but his job is to make sure that you have evidence for all the publications, courses, audits, presentation …etc that you have claimed on your application form. If you claim you have a publication or did an audit that you don’t have a document to prove it you will get into deep trouble. The third interviewer may not speak with you at all if everything is ok.
• Section1: You will be asked to give a 5 minutes presentation. The presentation should answer the question “what makes you suitable for training in cardiology” you should talk about your achievements and CV and convince the interviewers that you are an outstanding candidate. Once you finish they will ask you 2,3 questions usually related to your presentation or CV
  You will be given a mark out of 10 (5 from each interviewer) for your application and evidence of your career to dare.
• Section 2: You will be asked a series of 5- 8 questions about your understanding of the specialty, your understanding of training in the UK and questions to check if you have thought and planned for your training. You will be given a mark out of 10 (5 from each interviewer) for your suitability and commitment to the specialty.
• Examples for section 2 questions include: How do you see cardiology in 10 years, What do you think about multisource feedback, how do you see your self in 5 years ….etc

Station 2:

• You will be given 2 scenarios in this station and you will be marked on how you respond to them mainly your clinical judgement but also your communication skills. While waiting outside the station you will be given the first scenario only to read. Then you go in and discuss the first scenario followed by giving you a second scenario. For each Scenario you will be marked out of 10.
• In most scenarios you will be shown an ECG at some point during the discussion and asked to interpret it.
• At the end of at least one of the scenarios one of the interviewers will pretend he is the patient and ask you to explain the diagnosis. This is mainly to assess your communication skills.
• Example of scenarios include: patient presenting with SOB and have complete heart block, young patient presenting syncope and have Hypertrophic Cardiomyopathy ….etc

Station 3:

• There will be an ethical scenario and questions about clinical governance and professionalism. You will be marked on your suggested responses to the ethical scenario during discussion and your understanding of professionalism and governance.
• Section 1: you will be given an ethical scenario during the 5 minutes waiting before starting the station. You will then be asked ethical questions about the scenario and marked out of 10.
  Examples include: An elderly patient with dementia who presents with complete heart block, A patient with an implantable cardiac defibrillator comes to see you after having a device shock and wants to continue driving…etc
• Section 2: You will be given a shorter scenario/question usually 1-5 (variable) and asked about clinical governance and professionalism.
  Examples include what happens to incident forms, what will you do if your colleagues/consultants do something wrong, prescription errors….etc
  You will be given scores out of 10 in all the 6 sections of the interview. However these scores are not equal and each section is multiplied by a factor as per table below.

Section 9: Competition Ratio:

Find below a table showing the number of applicants, number of national training numbers and locum appointment for training for the last 4 years at a national level including Wales and Scotland (not Northern Ireland). Please note that from 2016 onwards there will be no LATS in England.

You will have noted that there was a significant increase in training numbers in 2016. This coincided with the abolition of LATs which may partially explain the increase. In 2017 it is very likely that the training numbers will be significantly less than 2016.

Section 10: Offers and Visa Issues and HEE

• After the interview candidates are classified into “appointable” and “unappointable”. Any one who gets 1/5 in any area or 2/5 in 4 areas are not appointable. If you get 2/5 in 1-3 areas you will be discussed in the interviewers meeting at the end of the interview to decide whether you are appointable or not.
• Candidates who are not appointable will receive an email within days after the interview to let them know that they were unsuccessful.
• Each deanery will make offers separately any time after the interview date. There is a deadline for the offers to be made.
• Once all offers are made and accepted by the candidates, the remaining candidates who are appiontable but did not score high enough to be offered a job will be invited to join the clearing round.
• If you do not have right to work in the UK i.e you are not British or EU citizen and not on a training programme (e.g. core medical training) at the time of application you will be informed that you will not be offered a job until the clearing round.
• Clearing round happens when some deaneries do not have enough appointable candidates to fill their jobs. There were 12 jobs in the clearing round in 2016 and 5 in 2015.
• All candidates from all over the UK will be ranked on one list and then offered the remaining jobs as per their ranking in the clearing stage.
• During the clearing stage candidates who have the right to work in the UK will be given priority over those who do not have the right to work in the UK.

Section 11: Speciality Exams

1. MRCP You will need to have passed all MRCP UK parts to be able to start training in Cardiology. This is the only mandatory Exam before applying.
2. When you are training in Echocardiography it is optional to obtain British Society of Echocardiography accreditation. To obtain the accreditation there are 3 steps. Firstly a theory exam, secondly collect cases for your log book (250 cases + 5 video cases) within 2 years of the theory exam. If you do the above you will need to pass a viva exam when you go to a centre and check your log book in addition to see you perform an echo.
   If you are able to do a full echo on a normal patient you can do the theory exam to demonstrate your commitment to the specialty but this is not essential.
3. In ST5 you will need to attempt the European exam fin general cardiology previously known as cardiology knowledge based exam (multiple choice question). However you are not allowed to do this exam if you are not on training.

Section 12: Speciality Courses/Societies

a. Advanced Life support is essential and your application may be rejected if you do not have an ALS certificate.
https://www.resus.org.uk/information-on-courses/advanced-life-support/
£450 (variable depending on centre)

b. IMPACT (ill medical patient acute care and treatment) course is on the desirable criteria and is usually done during core medical training.
http://www.impactmedical.org/
£350

c. British Cardiovascular Society
Joining the British cardiovascular society can demonstrate your commitment to cardiology and is useful if you want to know about cardiology courses. You can also join the British junior cardiologist association even if you are not in training.

http://www.bcs.com/pages/default.asp
£105 for joint memebership BCS + BJCA
http://www.bcs.com/pages/page_affiliate.asp?PageID=318

d. A career in cardiology
This course is organised by the British cardiovascular association and is designed to improve candidates chance of securing a training number in cardiology. It is highly recommended that you attend this course.
http://www.bcs.com/pages/page_box_contents.asp?PageID=736
The fee is not published yet

e. IRMER. It is essential that you attend an Ionising radiation medical exposure regulations (IRMER) course during training. You can do this course before you apply however it will not make a huge difference to your application.

f. Echocardiography:
– It is debatable whether you need to do an echo course or not. It can demonstrate your commitment to the specialty and help you learn the theory part of echo and some practical tips. However theses courses are expensive and you can demonstrate commitment by attending echo sessions in your hospital.

Midlands foundation Echo is a good one held 3 times a year in Stoke on Trent. http://www.midlandsecho.com/Midlandsecho/Welcome.html
Fees: £780

g. Coronary angiogram courses
– These type of courses are useful as an introduction to the cath lab and coronary angiograms. Although they may demonstrate commitment to the specialty, it is not essential to do them.

Mersey cardiac catheterisation course
http://www.merseymedicine.co.uk/
Fees: £50 only

Section 13: Rotations

1. The standard duration for cardiology training is 5 years. i.e ST3 – ST7. There is an option of extending one extra year (ST8) if you want to have dual accreditation (Cardiology + General Internal Medicine).
2. Typically 2 of the first 3 years are spent in a district hospital and the remaining years in a tertiary centre.
3. In tertiary centres registrars rotate to cover cardiology oncalls and CCU/wards but they spent the rest of the time training. In a district hospital usually registrars have 2 lab sessions, 1 echo sessions, 1-2 clinics, 1-3 ward rounds per week in addition to covering medical on-calls.
4. On-calls are usually 1 in 9 days to 1 in 14 days. In tertiary centres the registrars will answer cardiology calls, review referrals, usually cover CCU patients, cover the Primary PCI calls and do emergency Echocardiography. In most district hospitals the on-calls are medical registrar on-calls covering admissions or ward cover or both.
5. Life work balance: Cardiology is a tough medical specialty. Although the standard working day is 09:00 – 17:00, frequently registrars need to come 08:00 to review and consent patients before cath lab sessions or stay late after the list is finished 17:00 to review the patients who had procedures on the afternoon list. Training in Echocardiography is exhausting and registrars often stay late doing echocardiography to increase their numbers on the log book. You will also need to keep yourself up to date as there are a lot of developments happening in cardiology. Most cardiology consultants in UK are expected to be called at night when they are on-call and frequently attend the hospital at night (even non interventionalists).

Section 14: Ranking of Deaneries

• Ranking of deaneries is very subjective. The commonest factors that influence deanery selection include the number of training jobs, working in the deanery before applying, knowing influential people in the deanery and reputation of the centres.
• Every deanery has 1-4 excellent tertiary centres and many other small district hospitals (except for London where there are more than 4 tertiary centres).
• Every trainee will spend at least 2-3 years in one tertiary centre.
• A tertiary centre is a cardiology centre where there are cardiac surgery services. There are around 36 NHS tertiary centres in the UK.

Section 15: Wages / Take Home Cash

• The salary system in UK is complicated and there are multiple factors that influence the exact take home money. To complicate things further the pay system is going to change from August 2016.
• Roughly a cardiology ST3 (first year registrar) currently takes home after tax and deductions around £3000 /month (£2973). This used to increase annually by around £150 to a maximum of £3846 /month.
• The main change from August 2016 is that there will not be an annual increase i.e ST3 will have the same salary as an ST8. However the salary will likely be somewhere between £3400 -£3600 (not yet finalised). So it will be good for newly starting ST3’s but not good for those who are on the higher side of the scale.

Section 16: MTI

• Cardiology is part of the Medical Training Initiative scheme (see MTI section on this website for further details).

Section 17: Experience of Sudanese Doctors:

• As far as I am aware there are currently 17 Sudanese doctors training in Cardiology in YK. 3 of them were born and raised in the UK.
• At least 2 did not do a core medical training or acute care common stem training in UK.
• Nearly all (except 2 or 3) did not get into cardiology training straight after core medical training. Some of them did LATs and some did a mixture of LATs and service posts and some did research.
• At least 1 Sudanese doctor got into cardiology training by applying from Ireland. In other words, the first time he worked for the NHS was as a cardiology trainee.
• Eastmidlands, Westmidlands, Yorkshire and Scotland are the areas where currently 3 or more Sudanese doctors are training in cardiology. (This is just random and does not mean that these are the best places for applying or that it is more difficult to get a number anywhere else).
• There is no upper limit to how many years you worked in cardiology that prevents you from getting a training number. I know a registrar who worked as a cardiology registrar for 8 years before he finally got his training number (mixture of LATs and service posts). I also know someone who trained in his own country (not Sudanese) and practiced as a consultant there before moving to the UK and getting a training number 2 years later.

Section 18: Important Links and Websites

a.  ST3 recruitment website:  www.st3recruitment.org.uk
b.  British Cardiovascular Society: www.bcs.com
c.   Joint Royal college of Physicians Training Board:  www.jrcptb.org.uk
d. National cardiology handbook for new starters in cardiology training:
http://www.bcs.com/documents/BJCA_National_Cardiology_Induction_Handbook_-_2016.pdf