Dr John Joseph (JJ) Coughlan is a graduate of the Trinity College Dublin School of Medicine. JJ is currently an interventional cardiology research fellow in the German Heart Centre in Munich, Germany. He moved to Germany after four years of higher specialist training (HST) in Cardiology in Ireland. In this article, he discusses his experience in the field of cardiology and his secrets to success.
What inspired your decision to become a Cardiologist?
I still remember the patient that inspired my decision. I was working as an emergency department resident in Australia. An Asian man in his late 30’s walked into the emergency department complaining of chest pain. His ECG showed an ST-elevation pattern which was unusual for us because our centre was not a dedicated STEMI centre. The patient was brought up to the cath lab, his artery was opened up and stented and his symptoms resolved. I remember thinking ‘wow this is amazing!’. Percutaneous coronary intervention seemed like such a practical skill and to see the patient’s symptoms resolve with re-opening of the artery was incredible.
What are the most fulfilling parts of your job?
Being able to help patients is probably the most fulfilling part of any doctor’s job. Patients who are experiencing a myocardial infarction often have a sense of ‘impending doom’. They can present extremely unwell and feel like they are dying. To be able to open up their artery, resolve their symptoms and improve their clinical outcome is incredibly fulfilling.
In recent years, replacement of valves using minimally invasive techniques has also become commonplace in Cardiology. Transcatheter aortic valve implantation is a treatment for aortic stenosis where a new valve is implanted to replace a valve which has become calcified and no longer opens up very well. Patients with aortic stenosis are often unable to walk very far and can be limited in terms of their quality of life. Replacing their valve can often significantly improve their symptoms, restore their quality of life and improve their clinical outcome. It is very gratifying to see a patient regain their independence after such a minimally invasive procedure. Patients come back to clinic and report that they are now able to walk to the shops; it is always a nice moment to see how much this means to them.
What part of cardiology do you hate the most/find most frustrating, why?
I wouldn’t say there is any part of cardiology that I hate. I think that like many people working within systems with limited resources, it can be challenging to deliver the type of care you want to your patients. But this is a common issue in healthcare systems worldwide. For me, the best way to avoid frustration, is to put the patient at the forefront of everything that you do. One can easily get dispirited, but if we focus on doing the best we can with what we have it’ll go a long way.
What part of training would you improve if you could?
One area is in research support. It would be great if trainees could receive more training and support in clinical research. While trainees on basic and higher specialist training schemes are often encouraged to undertake research, they do not receive much formal training or guidance in this regard. In addition, most research performed tends to be on a trainees own time, without protected research time during the course of their normal week. This serves to disadvantage trainees with family or other commitments outside of work, who will potentially have less time available to them to take on additional research work outside of their normal working week.
What advice would you give to someone in med school/recent graduate who is considering cardiology?
My advice would be to get some exposure to the specialty. Apply for intern or SHO jobs which have a cardiology rotation. If you are a medical student, go down to the cath lab and ask if you can observe a procedure. People are always receptive when you show interest. Even more, you can start to get a sense of what the specialty is about and whether it interests you.
What has been the single biggest contributor to your success so far?
In my experience, hard work is the biggest contributor to success in general. However, I think that when you are doing something you are interested in, it is easier to work hard. Try to think about what you enjoy doing or what you are interested in, that might make all the hard work associated with pursuing a career in your chosen specialty feel that bit lighter.
I also think that it is important to enjoy the work you are doing. I hear a lot of trainees say that things will be better when they are an SHO, when they are a registrar or when they are a consultant etc. The reality is that there will always be challenges and stresses associated with your career, no matter the stage. There will never be a point when you have ‘made it’ and all your problems disappear. Learn to enjoy the process of working to achieve your goals.
What are the steps to getting on the Cardiology scheme in Ireland?
In Ireland, after your intern year you need to do the medical basic specialist training scheme (BST). Then you can apply for higher specialist training (HST) in Cardiology. Membership of the Royal College of Physicians is required to progress to HST. This is a three part exam which can be completed during the course of your BST, or after it. In order to be a competitive candidate for the HST in Cardiology, candidates will usually have undertaken some research and/or audit, demonstrated commitment to the specialty (perhaps by taking part in courses or conferences). Previous work with a Cardiology service during the course of their intern year or BST scheme is also essential.
What big changes are anticipated?
Cardiology is one of the most research driven medical specialities and new technologies are constantly being introduced into the market. In recent years, this has been most evident in structural heart disease, particularly valvular heart disease. Previously, open heart surgery was the only way of managing severe valvular heart disease. However, now there are minimally invasive therapies for all heart valves. While these are not yet suitable for all patients, I would anticipate that as technologies improve, more and more patients will be treated in this way. In the future, I think it is inevitable that these technologies will supersede cardiac surgery.
How valuable is research for trainee doctors if you are not interested in academic medicine?
I am probably biased in this regard, but I have found it is extremely valuable! I have been heavily influenced by reading the works of Richard Feynman, the Nobel prize winning physicist who wrote and spoke extensively on the scientific method. In Feynmans’ view, science is simple a way of figuring out ‘what works’.
I think it is reasonable to assume that the majority of doctors want to treat their patients with treatments that work. And research is the way that we figure out what that is. However, in order to be able to understand and critically analyse scientific papers, training is required. If a doctor can develop these skills, they have the ability to assess the scientific literature for themselves and figure out ‘what works’ for their patients. So in my opinion, even if a doctor is not interested in carrying out research or writing papers, the skill of understanding the scientific method and critically appraising evidence is invaluable.
You’ve been very productive in research, how did you go about building your research profile?
The most important first step in getting involved in research is putting yourself out there. Many trainees are unsure how to do this. Usually the best way is just to ask! Ask a consultant or a doctor on your team if there are any projects you can help with. In my experience, people are usually delighted to get interested people involved.
If your initial attempts to get involved in research are unsuccessful, do not be disheartened, be persistent. When you start, your first role may be data collection, cleaning a database or something similarly unglamorous! However, it is an opportunity to get started and to demonstrate that you can work efficiently as a member of a research team. This may lead to further opportunities to get involved with other projects in the future.
This is how my involvement in research started. Over time, my knowledge improved, and I began to undertake projects of increasing complexity and make connections. However, it is important to consider that this all takes time. Another important point is to appreciate that research is a collaborative process. It involves working with others and networking. So ask for projects, offer to help, get involved and see where it takes you!
What do you do outside of your medical/research work to stay grounded?
My favourite hobby is running, so I run 5 or 6 times per week. I think that one major issue for doctors is maintaining a healthy work-life balance. I’ve learned over the years that it is important to devote time to switching off and relaxing. In order to optimise your performance over the long term, learning to take care of yourself is essential.
What are your future plans/goals?
For now, I am focused on my research here in Munich. In the long term, I am interested in how clinical research can be better translated into real world practice. This involves not only how we can better incorporate evidence-based therapy into clinical practice but also how we can perform clinical trials on patient populations that are reflective of real-world practice.
