10-Minute Interview: Amit J. Shanker, MD

This month we speak with Dr. Amit Shanker, who heads the Center for Advanced Arrhythmia Medicine (CAAM) located at the Bassett Heart Care Institute, an affiliate with the Columbia University College of Physicians and Surgeons, in Cooperstown, New York. Why did you choose to work in the field of electrophysiology? I find cardiac electrophysiology to be intellectually stimulating with a very palpable procedural component. Much of the novel research in our field has fundamentally caused a paradigm shift in how arrhythmias are diagnosed and treated. It is difficult not to get caught up in both the excitement and controversy that surround the field today. Describe your role as an electrophysiologist. What is a typical day like for you? I can’t say I have a “typical” day. In addition to my ostensible responsibilities as a physician who provides EP services, I also have logistical administrative responsibilities involving direct oversight into the establishment of a thriving EP component to our health care system. This has involved hiring capable staff to run outpatient and inpatient services, ordering necessary equipment, negotiating with vendors for reasonable pricing, establishing quality control measures, educating existing staff, and marketing. I also have some teaching responsibilities to our medical students and residents. Tell us about the establishment of the Center for Advanced Arrhythmia Medicine. What types of procedures will be performed there? We perform implantation of devices and complex ablations. We will also become involved in a variety of clinical research trials. Luckily, the infrastructure is already in place to support research endeavors. What is the most memorable case you have ever been involved with? I have been involved in many memorable cases, so it is difficult to identify one particular case that stands out. I will say that with most cases, there is always something that I learn, however small it might be. What aspects of your work do you find most rewarding and/or challenging? The most rewarding aspects are of course treating our patients and getting feedback that we’ve made a difference, because that is our goal — not only to extend life but also to improve each individual patient’s quality of life. Short-term challenges involve establishing the infrastructure required to run an efficient EP service. A longer term challenge will be addressing the issue of reimbursements (both hospital and technical components). The issue will pose a formidable challenge for all physicians over the next 10-15 years. This will be more pronounced if the services provided by recovery audit contractors (RACS) — consultants hired by Medicare to recover large amounts of “overpayments” — become universal by 2010. We have already started seeing the effects of their efforts in the state of New York. Fortunately, the Heart Rhythm Society is ahead of the curve and has started addressing the issue. Are you currently involved in any EP-related research projects? Yes, we will be over the next three to six months, involving both pharmacologic and device-related therapies. What advancements do you hope to see in the field of cardiac electrophysiology in the next decade? What specific areas of EP and/or patient care need more attention? In the short-term, I see two emerging technologies that could transform the way EP is practiced: magnetically-guided navigation and leadless defibrillator technologies. Both these technologies could dramatically reduce the risk of procedural complications. In the long-term, I hope to see more advancements in anti-arrhythmic drug therapy (i.e., increased efficacy with lower incidence of end-organ toxicity), including “biopacemaking” with adenoviral vectors. In my judgment, inappropriate shock therapy is an issue that needs more attention. I would also like to see a more standardized approach as to how AF ablations are performed. Are there any particular websites or texts you would recommend to others in the field of EP? I believe Clinical Cardiac Electrophysiology: Techniques and Interpretations by Mark Josephson is the reference textbook in electrophysiology. Annual attendance at a national or international EP forum is important. What advice would you give to EP professionals who are currently at the start of their career? When in fellowship training, you learn the technical and theoretical aspects of EP. Once you get into practice, there is still a steep learning curve in terms of how you approach procedures. The biggest challenge that I grappled with was how I wanted to practice EP. I’ve made a sort of “reverse migration.” I was in private practice for three years and now have returned to more of an academic model. The decision to choose what type of practice setting to join is largely based on one’s experiences, circumstances and professional goals.