Commentary

Electrophysiology training in crisis

Fellowship numbers are down and reforms are needed.
 
Peter R. Kowey
 
Victoria M. Robinson
 
Douglas Esberg

In the past 5 years, we have witnessed a sharp decline in the number of cardiology fellows who have chosen to pursue advanced training in cardiac electrophysiology. While we have had cyclical shortages in the past, we are now witnessing an unquestionable reduction in the number of applicants. Last year was the worst yet. In the first year of the EP Fellows Match Program, we had just under 90 fellows applying to match at more than 150 U.S. training slots. Several prestigious programs were left with open positions.

The absence of electrophysiology (EP) fellows in an active cardiology training program is a sinister thing. Not only is it a strange and unsettling experience for the staff, but the enthusiasm and eagerness that fellows bring to an active arrhythmia program are sorely missed.

What are the causes for this fall in interest in EP as a career? How did we go from attracting the best and brightest fellows to join our subspecialty to a situation where fellows with potential in EP are choosing other paths such as advanced imaging and interventional cardiology? And, most importantly, how can we fix things?

Intellectual development lacking

The first step in coming to answers is to carefully consider what our cardiology fellows are observing of their mentors. First of all, they don’t see many women or people of color. We have not done a good job of attracting minorities to our specialty and our professional organizations have not made this a priority. What they do see are a lot of mostly bright men with insight into the complex anatomy and physiology of the heart’s electrical system that they under employ in their daily routine. The EP lab used to be a hotbed of inquiry in which everyone was expected to ask questions that could be addressed with thoughtful experimentation. We literally “learned while we burned,” with the expectation that we would figure out a way to rid our patients of common arrhythmias. We placed devices in people who had a history of sustained tachycardias or real conduction disease and saved them from recurrent sudden death or syncope.

Those same laboratories have been turned into procedure factories in which devices are implanted wholesale in patients, most of whom never use them. While this is the nature of primary prevention, these procedures do little to foster intellectual development. Fellows will rarely see the fruits of their labors since most such patients never reenter the hospital during their subsequent training.

Atrial fibrillation is the arrhythmia we treat most frequently, but about which we understand the least. Antiarrhythmic drugs are frequently but poorly used, with a paucity of new agents and little interest in new drug development. The “novel” non-vitamin K antagonist oral anticoagulants are not novel anymore. They have become the purview of general cardiologists and internists, as EPs compete with interventionalists to justify an expanding use of appendage occlusion devices.

Limited academic activity

Although we mandate that our fellows participate in some academic activity, their ability to obtain funding and to find the time to carry forward original research of any quality is quite limited. Only a small minority of our fellows have an opportunity to participate in basic research, and our current grant system has not fostered the development of clinician scientists. While a relatively small set of basic and clinical investigators continue to slowly push back our frontiers of knowledge, the vast majority of EPs have become technocrats, mired in a system that rewards volume and places almost no premium on insight. There is little time to measure refractory periods when three more patients undergoing AF ablation are sitting on stretchers outside the EP lab. At the end of the day, our graduates are well equipped to join a procedure-oriented practice that focuses on revenue and not knowledge generation.

Source: Data provided by the authors.

In many programs, EP specialists live in an impenetrable tower that is not seldom breached by the general cardiology fellows. Device interrogations are carried out by allied health care professionals to save time. Complex ablations are felt to be beyond their expertise, and the good old diagnostic EP study and simpler ablations for reentrant supraventricular tachycardias have become uncommon. If we don’t bring the fellows to the table at the beginning of their training career, how can they be attracted to a lifetime subspecialty?

We have also managed to complicate the training process itself. Consider that a fellow who is pondering EP training will face a minimum of 5 years of post-residency training. He or she will be expected to attain and maintain certification in multiple complex specialties and, while deferring employment, assume an immense financial burden. EP jobs are available in some areas of the country but are scarce in metropolitan regions that many fellows are attracted to for reasons related to their family or spouse. Jobs in the community may not provide sufficient volume, forcing a new staff person to spend considerable time seeing general cardiology patients and/or reading “nukes and echoes.” And though private practice salaries are usually fair, those who do choose to pursue an academic career can be disappointed.

Restructure fellowship

How do we make things better? First of all, we need to shorten the fellowship. Those who choose EP training should be obligated to do 2 years of general cardiology training followed by 2 years of training in EP. At the same time, we need to increase funding to make research grants available for all fellows who wish to spend an extra year in the basic lab or in clinical research, during which they can be absolved from clinical responsibilities.

We need to systematize the core curriculum. Programs with one or two fellows have a difficult time providing a full complement of didactic learning. In our current connected world, it should be relatively easy for professional organizations to construct a series of comprehensive lectures online, with local faculty providing commentary and answers to questions. These lectures can be supplemented by conferences in which fellows would be expected to present a case to the entire cardiology department followed by a discussion of the literature and recommendations for treatment.

We should consider capping the number of trainees any one center can take on while mandating a critical mass of attending physicians with a wide range of expertise in order to be certified to train fellows. Organized job counseling is a must and will need to start early.

Instead of exposing our fellows to a mind-numbing parade of routine patients, we could construct training lists with fewer patients, giving the trainees adequate time to absorb the relevant points. Patients could be selected for those lists depending on their presentation and pathology to enhance variety and interest. Cases can be similarly chosen to allow the fellow more time to think and to research.

Address occupational hazards

We need to address the occupational hazard that EP has become. Advances in shielding to avoid the lead burden, and of robotics and other techniques to minimize radiation exposure should reassure trainees, especially women who want to have children, that they and their families and their spines will not be threatened. This is a massive problem for women who not only fear radiation but the negative reaction of superiors when they need to recuse themselves from the laboratory.

Attending physicians should spend more time teaching physiology in the EP lab. That, and allowing clinical research projects into the lab, will undoubtedly reduce the number of cases each lab can perform daily. We will leave it to our hospital administrators to sort out the best way to deal with those logistics.

In exchange for time spared by not having to construct didactic lectures, clinical faculty can spend more time on organized mentoring, including ECG reading, a forgotten art. Fellows should be expected to spend at least 1 full day per week seeing patients in the outpatient clinic under direct supervision.

No choice but to try

Is it reasonable to believe that this laundry list of improvements can be implemented? More importantly, should we expect that their enactment will lead to a significant and durable increase in the number of EP fellowship applicants? Our belief is that we have no choice but to try. To maintain the status quo will inevitably lead to a continued diminishment in the quality of our profession because of the systemic problems described. That in turn could impact the quality of care that succeeding generations of patients can anticipate. But the window of opportunity is closing.

We appeal to our professional organizations to discuss and then to implement changes in the training paradigm without delay. And while so doing, they should certainly draw upon the time and the expertise of those of us who have leveled criticism of the existing system. It is time for everyone who cherishes our subspecialty to roll up their sleeves to begin the rejuvenation of EP training.

Disclosures: The authors report no relevant financial disclosures.

 
Peter R. Kowey
 
Victoria M. Robinson
 
Douglas Esberg

In the past 5 years, we have witnessed a sharp decline in the number of cardiology fellows who have chosen to pursue advanced training in cardiac electrophysiology. While we have had cyclical shortages in the past, we are now witnessing an unquestionable reduction in the number of applicants. Last year was the worst yet. In the first year of the EP Fellows Match Program, we had just under 90 fellows applying to match at more than 150 U.S. training slots. Several prestigious programs were left with open positions.

The absence of electrophysiology (EP) fellows in an active cardiology training program is a sinister thing. Not only is it a strange and unsettling experience for the staff, but the enthusiasm and eagerness that fellows bring to an active arrhythmia program are sorely missed.

What are the causes for this fall in interest in EP as a career? How did we go from attracting the best and brightest fellows to join our subspecialty to a situation where fellows with potential in EP are choosing other paths such as advanced imaging and interventional cardiology? And, most importantly, how can we fix things?

Intellectual development lacking

The first step in coming to answers is to carefully consider what our cardiology fellows are observing of their mentors. First of all, they don’t see many women or people of color. We have not done a good job of attracting minorities to our specialty and our professional organizations have not made this a priority. What they do see are a lot of mostly bright men with insight into the complex anatomy and physiology of the heart’s electrical system that they under employ in their daily routine. The EP lab used to be a hotbed of inquiry in which everyone was expected to ask questions that could be addressed with thoughtful experimentation. We literally “learned while we burned,” with the expectation that we would figure out a way to rid our patients of common arrhythmias. We placed devices in people who had a history of sustained tachycardias or real conduction disease and saved them from recurrent sudden death or syncope.

Those same laboratories have been turned into procedure factories in which devices are implanted wholesale in patients, most of whom never use them. While this is the nature of primary prevention, these procedures do little to foster intellectual development. Fellows will rarely see the fruits of their labors since most such patients never reenter the hospital during their subsequent training.

PAGE BREAK

Atrial fibrillation is the arrhythmia we treat most frequently, but about which we understand the least. Antiarrhythmic drugs are frequently but poorly used, with a paucity of new agents and little interest in new drug development. The “novel” non-vitamin K antagonist oral anticoagulants are not novel anymore. They have become the purview of general cardiologists and internists, as EPs compete with interventionalists to justify an expanding use of appendage occlusion devices.

Limited academic activity

Although we mandate that our fellows participate in some academic activity, their ability to obtain funding and to find the time to carry forward original research of any quality is quite limited. Only a small minority of our fellows have an opportunity to participate in basic research, and our current grant system has not fostered the development of clinician scientists. While a relatively small set of basic and clinical investigators continue to slowly push back our frontiers of knowledge, the vast majority of EPs have become technocrats, mired in a system that rewards volume and places almost no premium on insight. There is little time to measure refractory periods when three more patients undergoing AF ablation are sitting on stretchers outside the EP lab. At the end of the day, our graduates are well equipped to join a procedure-oriented practice that focuses on revenue and not knowledge generation.

Source: Data provided by the authors.

In many programs, EP specialists live in an impenetrable tower that is not seldom breached by the general cardiology fellows. Device interrogations are carried out by allied health care professionals to save time. Complex ablations are felt to be beyond their expertise, and the good old diagnostic EP study and simpler ablations for reentrant supraventricular tachycardias have become uncommon. If we don’t bring the fellows to the table at the beginning of their training career, how can they be attracted to a lifetime subspecialty?

We have also managed to complicate the training process itself. Consider that a fellow who is pondering EP training will face a minimum of 5 years of post-residency training. He or she will be expected to attain and maintain certification in multiple complex specialties and, while deferring employment, assume an immense financial burden. EP jobs are available in some areas of the country but are scarce in metropolitan regions that many fellows are attracted to for reasons related to their family or spouse. Jobs in the community may not provide sufficient volume, forcing a new staff person to spend considerable time seeing general cardiology patients and/or reading “nukes and echoes.” And though private practice salaries are usually fair, those who do choose to pursue an academic career can be disappointed.

PAGE BREAK

Restructure fellowship

How do we make things better? First of all, we need to shorten the fellowship. Those who choose EP training should be obligated to do 2 years of general cardiology training followed by 2 years of training in EP. At the same time, we need to increase funding to make research grants available for all fellows who wish to spend an extra year in the basic lab or in clinical research, during which they can be absolved from clinical responsibilities.

We need to systematize the core curriculum. Programs with one or two fellows have a difficult time providing a full complement of didactic learning. In our current connected world, it should be relatively easy for professional organizations to construct a series of comprehensive lectures online, with local faculty providing commentary and answers to questions. These lectures can be supplemented by conferences in which fellows would be expected to present a case to the entire cardiology department followed by a discussion of the literature and recommendations for treatment.

We should consider capping the number of trainees any one center can take on while mandating a critical mass of attending physicians with a wide range of expertise in order to be certified to train fellows. Organized job counseling is a must and will need to start early.

Instead of exposing our fellows to a mind-numbing parade of routine patients, we could construct training lists with fewer patients, giving the trainees adequate time to absorb the relevant points. Patients could be selected for those lists depending on their presentation and pathology to enhance variety and interest. Cases can be similarly chosen to allow the fellow more time to think and to research.

Address occupational hazards

We need to address the occupational hazard that EP has become. Advances in shielding to avoid the lead burden, and of robotics and other techniques to minimize radiation exposure should reassure trainees, especially women who want to have children, that they and their families and their spines will not be threatened. This is a massive problem for women who not only fear radiation but the negative reaction of superiors when they need to recuse themselves from the laboratory.

Attending physicians should spend more time teaching physiology in the EP lab. That, and allowing clinical research projects into the lab, will undoubtedly reduce the number of cases each lab can perform daily. We will leave it to our hospital administrators to sort out the best way to deal with those logistics.

PAGE BREAK

In exchange for time spared by not having to construct didactic lectures, clinical faculty can spend more time on organized mentoring, including ECG reading, a forgotten art. Fellows should be expected to spend at least 1 full day per week seeing patients in the outpatient clinic under direct supervision.

No choice but to try

Is it reasonable to believe that this laundry list of improvements can be implemented? More importantly, should we expect that their enactment will lead to a significant and durable increase in the number of EP fellowship applicants? Our belief is that we have no choice but to try. To maintain the status quo will inevitably lead to a continued diminishment in the quality of our profession because of the systemic problems described. That in turn could impact the quality of care that succeeding generations of patients can anticipate. But the window of opportunity is closing.

We appeal to our professional organizations to discuss and then to implement changes in the training paradigm without delay. And while so doing, they should certainly draw upon the time and the expertise of those of us who have leveled criticism of the existing system. It is time for everyone who cherishes our subspecialty to roll up their sleeves to begin the rejuvenation of EP training.

Disclosures: The authors report no relevant financial disclosures.