Why not? I asked myself. Why not attend an early-career session on choosing electrophysiology?
Day 1 of the American Heart Association (AHA) 2014 Scientific Sessions is a warm-up of sorts. The big effort—of learning from these massive sessions—looms large. It's like bike racing; you have to get the engine hotted up before the race. At AHA, the engine in need of warm-up isn't physical, it's mental and, to be truthful, emotional—eg, the passion for doctoring. For it is exactly that—passion, that is—that is the doctor's sinus node.
The early-career session, given by oldsters for youngsters, fulfilled its promise. Indeed, it is rare to feel emotion in a convention hall. When Dr Eric Prystowsky (St Vincent Hospital, Indianapolis, IN) launched into his philosophy of doctoring and Dr David Callans (University of Pennsylvania, Philadelphia) remembered his EP training as a great-books program, I felt it. It was a surge of warmth about being an electrophysiologist, about being lucky and grateful to my mentors.
Maybe it's just that I am goofy. Maybe it's the stage of my career. But lately, I've found myself thinking a lot about the field of electrophysiology.
My thoughts run the gamut, from dark thoughts, like EP is extra, a specialty fueled by the luxuries of an overconsuming society. AF is surely our engine of growth, but the disease entangles itself so tightly with societal riches. It is no small association that the US is the global epicenter of both AF and obesity. I often wonder whether my skills of persuasion—eat right, exercise, etc—might be more valuable than my skills in moving a catheter. I know, I know—these are heretical notions. Sorry.
Then my mind echoes back to the beautiful thoughts: the patients, young and old, we cure with a single ablation lesion; the heart-failure patient synchronized back to life with an LV lead; the mother who lives to see her kids grow up because of an appropriate shock; or perhaps the grandest part of being an electrophysiologist: seeing the squiggles of an ECG as if they were a human face. Yes, of course, it is preexcited. It is a left posterior pathway.
Enough soft stuff. Here is the session report. I took notes on Evernote and recorded the words. Prystowsky went first.
Disruption is the rule. Be ready. "Disruptive technologies will derail the best predictions." It's interesting (for a few reasons) he used FIRM ablation as a current example of disruption. FIRM ablation can surely be called intriguing and exciting, but debate remains on whether it's disruptive, yet.
Implanting devices is not the future. Learn an EP-specific skill. Complex ablation skills are your job security. I've disagreed with Prystowsky in the past, but not on this one. Gene therapy promises to replace implanted titanium and silicone. When that happens, he said, "any Tom, Dick, or Harry will be able to inject pacemaker stem cells to cure bradycardia." Second, leadless pacemakers will soon be combined with subQ ICDs, neither of which requires an electrophysiologist to implant. Third, real-world data show device implants are down. The median number of implants per EP physicians is only 22 per year.
Avoid staking your career on something with easy entry. Some of his friends are business leaders. They say never open a restaurant. Anyone can do it. He then showed a slide of an electrophysiologist surrounded by a pack of wolves. Each image of a wolf was adorned with an "IC" text box. IC stood for interventional cardiologist. "Stents are down. They are coming for you. They will eat your lunch," he warned.
Success depends on the Ps and Qs. The Ps are passion, punctuality (especially in returning peer reviews to his journal), preparedness, perfection, patience, persistence, politeness, and personable. Q is quality of life. Early in your career, you lean on the Ps. "Don't come with excuses. We are all busy." But, he added with emphasis, "Never miss a nonrepeatable event. You may not remember the missed soccer game, but your daughter will." (Insert wave of emotion here.)
Life is a balance. Get another interest. Diversify. The P/Q ratio should change over time. Ps give way to Q. "The medicine part is easy, straightforward, but if that's all you do, it can become drudgery." A couple of his colleagues are retiring this year. He asked them why. "You don't get it, Eric," they said. "You edit a journal, you travel, your life is good. We are done; we are burned out."
Don't worry about your salary. "You will make plenty of money. Not as much as we used to, but enough. Your real reward is in helping people. Remember that you cure people, which is different from other areas of cardiology."
Three practical lessons. Don't see new patients after 2:00 pm. Your empathy is shot by then. Second, enjoy the free time of canceled appointments. Don't worry, they will reschedule. Third, get an interest outside of practice.
Callans went next.
He also offered useful advice. He agreed with Prystowsky's thesis that change is the norm. "I don't do any of the things now that I did in fellowship," Callans said. This is a noteworthy point. I am a little younger than Callans, but AF ablation and cardiac resynchronization therapy (CRT) were not yet ideas during my training.
Be prepared to learn new techniques. Six years. That's how long it took me to become comfortable with point-to-point RF ablation of AF. Callans said it was hard to learn new things after the protected time of fellowship. I'll say.
Learn to multitask without panicking. "Embrace the Zen part of the job. Have the confidence you can do all this and still keep centered." Really, he said this. I recorded it. (Insert another wave of emotion.)
The EP lab is no longer the oracle at Delphi. "For better or worse, lots of people are interested in what's happening in the EP lab." Diagnoses and plans for treatment no longer get decreed from a review of rhythm strips. We communicate more than ever, with colleagues, with patients, with nursing staff. EP is no longer in a silo.
Specific knowledge sets to learn include the autonomic nervous system, interventional techniques (epicardial access), and advanced imaging. Intracardiac echo (ICE), in particular, was mentioned as a way to disrupt transesophageal echocardiography (TEE). Recent studies suggest left atrial appendage imaging might be better with ICE. I'm going to start working on this technique when I get home.
Embrace new technology, but do it with a healthy skepticism. You will have to make hard calls on whether a new technology passes muster for your patients. LAA appendage occlusion leaps to my mind here. Callans sort of agreed, saying, "I don't know what to say about LAA occlusion."
Team building is key. You will need to network. "The heart-rhythm community is individualistic, almost to a fault," Callans said. Again, I concur. The knowledge gap in heart-rhythm disorders is large. To doctor is to teach. Heart-rhythm wise, there is a lot of teaching to be done in the real world. It will require a team.
I left the session smiling, with a feeling of being content, grateful, and fortunate. Although the take-the-fun-out-of-medicine people are many in number and strong in will, our victories still win out.
No. The future of EP is not bleak.
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Cite this: Day 1 AHA: The Future of EP Is Not Bleak - Medscape - Nov 16, 2014.