level 2 EP

[AZhopeful]

I am a new cards fellow this year, and I was surprised to find out on July 1st that our program has a policy of not allowing fellows to achieve level 2 in EP. Our PD is an EP doc and told us that this is because he/she thinks that implantable devices are too complicated for general cardiologists to responsibly be implanting and one should do an EP fellowship to do them. This was kind of a surprise to me based on my experience interviewing with other programs. This wasn't really discussed on my interview day here; in fairness I had not directly asked about it because I did not think it would be an issue. I have talked to some people both within our program and former alumni who think it is more of an issue of our EP group not wanting any more competition, as the PD and the other electrophysiologist are already going to multiple other hospitals to get more procedures.

Im curious to see if anyone in the cards forum have any thoughts on this. Does the reason that we were given on July 1 seem, well, reasonable? Has anyone had a similar experience?

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[P Diddy]

I am a new cards fellow this year, and I was surprised to find out on July 1st that our program has a policy of not allowing fellows to achieve level 2 in EP. Our PD is an EP doc and told us that this is because he/she thinks that implantable devices are too complicated for general cardiologists to responsibly be implanting and one should do an EP fellowship to do them. This was kind of a surprise to me based on my experience interviewing with other programs. This wasn't really discussed on my interview day here; in fairness I had not directly asked about it because I did not think it would be an issue. I have talked to some people both within our program and former alumni who think it is more of an issue of our EP group not wanting any more competition, as the PD and the other electrophysiologist are already going to multiple other hospitals to get more procedures.

Im curious to see if anyone in the cards forum have any thoughts on this. Does the reason that we were given on July 1 seem, well, reasonable? Has anyone had a similar experience?

The writing's on the wall. The data suggest that those who do more of a certain procedure have less complications. This pertains to ICD placement too: see Freeman et al, JACC 2010.

Would you rather have someone placing 10 ICDs a week put your ICD in, or 10 ICDs a year?

You could always go to Mexico with Medtronic and learn how to put used pacemakers in poor mexicans who have no other option, but I wouldn't recommend it.

There is already a glut of electrophysiologists and not enough procedures. With the growing trend toward certification, the only places that will allow general cardiologists to place devices will be rural areas with no other options.


p diddy

 

[nstemi]

general cardiologists shouldn't be putting in devices unless there are no other options in your area

 

[sacrament]

I guess I will be the voice of dissent. With the exception of BiVs (which can be a hassle and a half), device implantation is, in my humble opinion, fairly trivial. I don't do it anymore because I don't enjoy it and I have other ways to spend my time, but I rarely found it to be a technical challenge. Sure, there is certainly an improvement in outcomes with volume, and if what we're saying is that only high-volume specialized operators should be sought after as device docs, then you'll find no disagreement from me. But formalized EP training isn't the only way to develop this skill, and it may not even be the best way. If the only aspect of EP that you're interested in is devices, then the rest of EP training will be a dilution and waste of your time.
In my community, the guy who does the largest volume is a general cardiologist who does no other invasive procedures, and he is who I send all my cases to. I haven't known him to ever have a significant complication, while I can't say the same for some of the EP-trained folks. Here, the general and interventional cardiologists are the ones doing most of the devices, and EP is doing studies and ablations. I think the bottom line is that if you have the numbers and the experience then you have the numbers and experience, and whether you attained it in an EP program or not is irrelevant.

 

[P Diddy]

...if what we're saying is that only high-volume specialized operators should be sought after as device docs, then you'll find no disagreement from me. But formalized EP training isn't the only way to develop this skill, and it may not even be the best way...I think the bottom line is that if you have the numbers and the experience then you have the numbers and experience, and whether you attained it in an EP program or not is irrelevant.

Agree completely. The issue is that the programs where you can get that experience outside of EP fellowship (as evidenced by OPP) are dwindling. It's a matter of time before they're gone.

p diddy

 

[AZhopeful]

Thanks for the discussion- I just wanted to see what some of the prevailing opinions were. I respect P Diddy's opinion; you also noted the rural areas/low availability point and it just so happens that this program is in a state, and a region of the country, that has lots of those rural areas with a significant population that lives 4-6 hrs driving distance from an EP doc. That, as well as sacrament's thoughts and the fact that some previous alums had had friction w/ the program because there were planning on setting up shop in those rural areas, are why I had questioned my program's policy.

I just like to use SDN as a reality check/source of new opinions sometimes, since the opinions that I am exposed to get a little stale when they've been couped up in the ivory tower for so long.