Sparking Interest in Cardiac Electrophysiology

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SS 209: Sparking Interest in Cardiac Electrophysiology

Session 209

Dr. Hemel Nayak is an academic cardiac electrophysiologist. He talks about his experiences and gives advice to students interested in cardiac electrophysiology.

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Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:21] Interest in Cardiac Electrophysiology (EP)

Going into internal medicine, Hemel wanted to choose a field that would allow him to work with his hands. As an internal medicine resident, that leaves you with specialties like gastroenterology, cardiology, and pulmonary care medicine.

Out of these three fields, Hemel felt cardiology might be able to provide the most impact in terms of the things he would do. He also likes the patient population and the pathophysiology of the cardiac diseases he encountered. And that’s what led him to cardiology.

As for choosing between surgery and medicine, he chose medicine – being more of a thinking person’s field. He also didn’t love being in the operating room all the time. 

'If you don't love being in the operating room, then surgery is not for you.'Click To Tweet

Hemel also enjoyed seeing patients, talking to them, taking care of them, and the idea of seeing patients longitudinally. And he thinks that being a surgeon, you may not have that ability to do as much.

[03:05] Traits That Lead to Becoming a Good Cardiac Electrophysiologist

Hemel can’t stress enough the importance of patience because the field can be intellectually very challenging. So you have to take the time to understand and think about what you’re seeing, especially when they do complex procedures.

You also need to have a sense of investigation since many things are not handed to you. For instance, when they do an EP study, they have to figure out what the patient has, which is the fun part of what they do in EP.

[04:11] Myths or Misconceptions About Cardiac EP

Hemel says people often view EPA as a black box where they don’t know what goes on there. People go into these procedures and they come out and they have no idea what happens to them. Hemel describes EP to be very logical and methodological.

Another misconception is that EP is too difficult. And Hemel clarifies that there are certain basics that you do need to understand when you go into EP. But when you want to at least attend an EP procedure, you can build upon that foundation and things start falling into place.

One other misconception is that they’re a bunch of nerdy cardiologists. But Hemel begs to disagree claiming that they’re actually a very fun bunch of people.

[05:10] Types of Patients

They see patients from 16 years old onwards. A lot of young patients have things like super ventricular tachycardia. On the other end of the spectrum, they see older folks who may have complete heart block who will need devices.

“EP runs the gamut in terms of age group and in terms of the health of the patient.”Click To Tweet

They see patients with normal hearts who just happen to have an electrical issue as well as patients with severe LV dysfunction and heart failure. They also see pregnant women with dysrhythmia. And so, you get to see a broad spectrum of patients.

In terms of the percentage of procedures, Hemel says this depends on the practice you want to set up for yourself. But in his practice, the yield from seeing a patient and having a procedure done is anywhere between 30 to 50%, depending upon the day.

[07:14] Typical Week

Hemel is in an academic practice so he’s a full-time faculty member. He has a full-day clinic that he sees at the hospital. On clinic days, he sees anywhere from 25 to 30 patients the whole day. He also has help from a cardiac elite EP fellow and general cardiology fellow that see some patients with him.

In terms of procedural days, most electrophysiologists are in the lab anywhere from three to four days a week. Those can be long days. On average, an electrophysiologist might do two ablations and a device in one day, or they may have four devices in one day. It’s a very complex case. And so, the days generally start anywhere from seven to 7:30 in the morning, and they last until around five to six for both procedural days and clinic days.

[08:29] Taking Calls & Life Outside of the Hospital

Even in practice, where call is the bane of everyone’s existence, if you have EP-only call, Hemel says you generally get bothered by EP questions. And there are only a few EP emergencies. EP doctors come in for things like VT storm.

For example, somebody has an infected pacemaker defibrillator. They’re in septic shock and that device has to be removed. So they will come in and do an emergent extraction.

Aside from that, calls are pretty good. They’re not getting up at two in the morning running in to do a STEMI or treat somebody with cardiogenic shock like their heart failure colleagues are doing

Obviously, they also get to have life outside of the hospital. And this mainly depends on your interests, where you are, and your level of career.

The key is to purposely make time for the things that are important to you.

[10:48] The Training Path

After four years of medical school, you do three years of Internal Medicine. Then you do three years of cardiology, and then two years of clinical cardiac electrophysiology.

A few years ago, the EP program went from a one-year program to a two-year program.It’s mandatory three years of general cardiology followed by two years of EP. The reason for the increase in training period is they do a lot more complex procedures. And so, the ACGME felt that a two-year program was necessary to learn the breadth and depth of electrophysiology.

'We work in a field where technology really drives what we can do for patients.'Click To Tweet

Hemel adds there are certain things they do in electrophysiology that are very impactful to patients. And so, that requires a certain level of training and expertise.

[12:43] Further Opportunities to Subspecialize

Within the fellowship, there are folks that enjoy doing specific type of procedures. And so you may go to a training program that’s heavy in VT ablation. And then when you finish, you want to go to an academic center.

You can become the VT person recruited by an academic institution to specifically do this program, run the program, start the program or be the main person. 

There are some people that do similar decisions for lead extraction. For example, they could recruit you to start a lead extraction program. So they want you to come out of your fellowship proficient in this type of technique.

Most people who go into private practice end up doing a little bit of everything in electrophysiology. And they may join a practice that may not have, for example, the infrastructure to do lead extraction or VT ablation. That being said, everybody in EP knows how to do the bread and butter cases and everyone learns to do those.

[13:45] Overcoming Negative Bias Towards DOs

As the fellowship director in their institution, Hemel says they just went through the interview process right now. And they look for somebody coming from a good training program in cardiology. You obviously need to have good letters of recommendation, but also some investigation.

If you have some sort of interest in electrophysiology, where you’ve done some research, try to submit an abstract on a particular topic. Show you’re working on something now with one of your mentors that shows us you have a keen interest in electrophysiology.

It doesn’t mean you have to have a public paper published, but just some story to tell that this is what you were interested in, this is what you’ve done so far, and this is what you wish to continue.

[15:10] Message to Future Primary Care Physicians

Atrial fibrillation is the most common arrhythmia we see in the United States. It’s the most common arrhythmia associated with stroke in the United States. And so, the primary care physicians are the ones at the forefront. 

Hemel says you could refer directly to electrophysiology. They love primary care referrals directly to them. Or the cardiologist can refer to them as well. But generally, they rely on that primary care group to be the first person that recognizes that person has atrial fibrillation.

Whether Hemel is a pro or anti ECG on the Apple Watch, he says they really don’t have a choice since it’s happening. And so, they just have to learn how to live with it. 

And so he recommends that if they decide to invest in an Apple watch with ECG or get one of those downloadable apps, you can get your single-lead ECG. Then the EPs could potentially do more external monitoring. And this is part of his discussion with the patient.

[17:01] Other Specialties They Work the Closest With

As an EP, Hemel works closely with cardiologists, especially the heart failure physicians. They care for a number of mutual patients. They work closely with our interventional doctors when they do a complex ablation if they need to provide them with mechanical support. They also work with their general cardiologist and imagers.

Outside of cardiology, people they often interact with our CT surgeons who back them up when they do complex lead extraction.

[17:48] What He Wished He Knew Before

Hemel admits he underestimated how much technology changes. There are procedures and techniques he does now that he never was trained to do so you learn on the job. And so, he wished he had known that that there’s going to be a lot of on-the-job learning. Then he would have prepared himself for it a little better.

He also wished he had a bit more experience in statistics and trial design because that’s in an academic practice. They actually enjoy doing those things and he’s learning as he’s doing those. But if he had that background, Hemel thinks things would have been a lot easier for him.

[18:37] The Most and Least Liked Things

Hemel likes the the fact that he can learn or see something he hasn’t seen almost every day. He will see a nuance, or a tracing, or a presentation that he hadn’t seen before. And so, he’s learning something new almost every day.

On the flip side, what he likes the least is how it can sometimes be mentally tiring due to the complexity of the case. He says it’s sometimes nice to get an easy case where you can just coast through it. Because when you have tough case after a tough case, it can get a little tiring. But that’s part of the job.

In such case, he just makes sure to reflect on what he did for the patient. No matter how they strive to do things, sometimes it’s just not in the cards. 

'It's self-reflection and then move forward and having an honest discussion with yourself, I think makes a huge difference.'Click To Tweet

[21:45] Major Changes Coming to the Field

Hemel thinks their procedures are going to get a lot more effective, a lot quicker to perform, and hopefully, safer. The technology is heading towards those those three aspects of the procedures they do. And in 10 years, the techniques he uses now will be outdated.

'Technology is really moving quickly.'Click To Tweet

[22:09] Final Words of Wisdom

If he had to do it all over again, Hemel says he probably would still have chosen EP. When you’re in undergrad, you don’t know what you’re going to major in. You kind og like a little bit of everything. When you’re in medical school, you’re torn between choosing one versus the other.

And Hemel says he would definitely do cardiology. Some of the things that excite him now when he sees his colleagues work is the heart failure group with LVAD ‘s and success in transplant. And he finds this very exciting. So if he didn’t do EP, he might do advanced heart failure.

Finally, he wishes to tell students and residents who might be interested in EP that electrophysiology is a great field. 

It’s great even particularly for female cardiologists for a number of reasons. First, it’s intellectually challenging. Second, even though the days are long, it’s nice. Third, is they have gone from a heavy floor field to almost a low floor to no floor field in a lot of the procedures they do. And this was a concern for a number of female physicians. Hemel says theyneed to have more women in electrophysiology. They need womens’ voices and their care.

For the non-female physicians looking into cardiology, it’s a great field that you get to work with your hands. 

'If you're on the fence between medicine and surgery, and you're you want to sort of do some surgical stuff, this is a great field to pick.'Click To Tweet

Hemel adds that electrophysiology is the perfect combination of medicine and surgery. He implants devices as well as performs lead extraction and a lot of the surgical things. They also do an EP, and so it’s a nice mix of both.


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