Top 10 Tips for New (and Future) Electrophysiology Fellows

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EP LAB DIGEST. 2024;24(12):1,8-9.

Chaun Gandolfo, DO Clinical Cardiac Electrophysiology Fellow (Year 2), Henry Ford Health, Detroit, Michigan; Marc K Lahiri, MD Cardiac Electrophysiologist and Director, Clinical Cardiac Electrophysiology Fellowship, Henry Ford Health, Detroit, Michigan

You have done this before. Seemingly countless times throughout your educational journey, you have successfully transitioned from one stage of your training to the next. Yet for many, the transition into clinical cardiac electrophysiology (CCEP) fellowship feels different from all the others. For starters, this is likely your last stage of training before you enter the “real world.” And for many, the new skills and knowledge you are now asked to master seem far more substantial than ever before. While it is true that by now you have trained more than most other physicians and are thus well equipped to handle new challenges coming your way, it is important to recognize that beginning your CCEP fellowship is likely the most daunting step you have taken thus far. With this in mind, we have compiled a list of our best suggestions to help you navigate this transition more confidently and successfully. 

Here are our top 10 tips (in no particular order) for new and future CCEP fellows:

1. Realize this is a BIG step up. In your prior transitions completed until now, you largely already knew what to expect from the next step. From medical school into residency and residency into fellowship, the next phase ahead likely already felt at least somewhat familiar. Yet for most graduating cardiology fellows, the world of EP seems entirely foreign. Skills such as interpreting intracardiac electrograms (EGMs), navigating 3-dimensional (3D) electroanatomic maps, and deciphering device interrogations are largely unfamiliar to most incoming CCEP fellows. Questions may come up, such as, “Is this too much for me?”, “Am I smart enough to understand these esoteric concepts?”, or “Am I skilled enough to perform these complex and diverse procedures?”. It is important to realize that these insecurities are normal. It can take 6 months or more to achieve the comfort needed in your knowledge base and procedural skills before you really start enjoying this amazing subspecialty. Realize that all incoming EP fellows have gone through the same process, and that comfort and confidence will come with time and experience.

2. Preparing minimizes perspiring. As with anything, being organized and prepared will help minimize stress. This is particularly important in a procedural subspecialty such as EP. Reviewing cases the day/night before can help you mentally plan for what to expect during the case. Knowing details about your patient’s history is vital to ensuring procedures are being performed as safely and efficiently as possible. It is not uncommon that you will need to make unanticipated procedural decisions about your patients while scrubbed into the case, so being prepared with all the pertinent information can be profoundly helpful. Such preparation will help you in clinic as well. Reviewing your scheduled patients the day before can help ensure a smooth and efficient clinic day, allowing for time to read about and discuss pertinent topics with your attending physician between patients instead of rushing to finish charting. 

3. Remember that the best leaders can do everyone’s job. The operating physician leads the team in the EP laboratory. Others will look to them for guidance, especially when things are not going well. As a fellow, take time to learn what the nurses and technicians are doing for each case. Learn which nurse and/or technician member of the EP laboratory is most experienced with EP procedures. Learn to cultivate these relationships. They are important. Catheter ablations are highly complicated procedures involving complex interconnecting technologies, and troubleshooting equipment errors and noisy EGMs is a part of seemingly every case. Learn how the staff prepares the laboratory, patient, table, and equipment. Learn all the cables, connections, and hardware settings for each type of procedure. This knowledge will pay dividends as you inevitably face these challenges every case. You will be surprised at how important these skills will be to help cases move along efficiently, and the laboratory staff will appreciate your attention to these responsibilities as well. 

4. Do not gloss over the basics. Incoming fellows are often most excited about the latest breaking research and newest exciting technologies in EP. While these things are indeed a big factor drawing electrophysiologists to this field, try to avoid this temptation when you start. Spend your time early on to really understand the foundational principles upon which everything else is built. Basic concepts such as voltage, impedance, refractory periods, or mechanisms of cellular physiology may seem mundane. However, they are critical to form the foundation upon which the more exciting concepts are built. Start by mastering these basics to enhance your learning and appreciation of the more complex intricacies in this field later on. 

5. Know your anatomy. While electrocardiograms and EGMs may first come to mind when one thinks about EP, cardiac anatomy is a surprisingly critical aspect of EP practice. Up until now, you could have gotten through your cardiology training with a limited grasp of cardiac anatomy. In EP, to be able to maneuver catheters throughout each of the 4 cardiac chambers, you will need a solid grasp of cardiac anatomy. One of the more challenging aspects of your training early on is understanding how everything is related in 3 dimensions and how you need to manipulate your catheters to get from point A to point B. You have multiple tools to help you, including intracardiac echocardiography, fluoroscopy, and 3D mapping systems. Learn how to correlate each of these technologies with your mastery of the underlying anatomy. A helpful resource to gain comfort with cardiac anatomy is the recently published Atlas of Interventional Electrophysiology.¹

6. Find a handful of resources and stick with them. There are countless textbooks and resources to help you study and learn concepts. Your program will surely have didactics and one-on-one learning opportunities with attendings, but given how expansive EP is, you will need to find other resources to help fill in gaps and strengthen understanding. Unfortunately, because there are so many different resources to choose from, it is easy to want to get through them all and then end up not getting through any. Choose a resource that provides a comprehensive review of EP and then some resources that focus on topics such as device management and intracardiac EGMs. We have found that the American College of Cardiology’s EP Self-Assessment Program (https://www.acc.org/Education-and-Meetings/Products-and-Resources/EPSAP) to be a useful resource that includes concise text to supplement videos along with a robust questions bank. Using workbooks that teach device management and intracardiac EGMs through case studies can be a way to stay engaged versus traditional textbooks. A list of additional resources are available at the end of this article, but this is by no means a comprehensive list. Engaging “seasoned” device clinic nurses or technicians can also be a valuable source of information and lived experiences.

7. Use industry-sponsored education. We work with several different device and mapping companies in EP, all of whom have their own proprietary technologies and workflows. Learning the nuances and intricacies of each separate system can seem daunting. Thankfully, most of these companies have educational materials to help learn management and troubleshooting techniques for those platforms. There are also many in-person or virtual conferences throughout the year that are sponsored for fellows. These can be a great way to spend time learning about a specific topic and bond with other EP fellows outside of work. 

8. Dust off your surgical skills. For many, the last time surgical skills such as cutting, cauterizing, suturing, or knot tying were practiced was during medical school clerkships years ago. It is time to wake those neurons back up. Pacemaker and defibrillator implantation are surgical procedures where these skills are critical for success. Take some time to become refamiliarized with basic surgical instruments. Borrow suture kits from the operating room to sharpen knot tying muscle memory at home. These skills take considerable time to master comfortably, so getting a head start before beginning CCEP fellowship can let you hit the ground running. 

9. Spend time in the EP laboratory before starting EP fellowship. Most cardiovascular disease fellowships have an abundance of elective time in the third year. Spend some of this elective time in the EP laboratory getting comfortable with the flow of procedures and the day-to-day aspects before starting as a CCEP fellow. This is also an opportunity to work with the current CCEP fellows who, since they are closer in training, can offer certain insight and teaching that attendings may not be able to convey as effectively. Other electives that can be helpful include advanced imaging such as computed tomography and magnetic resonance imaging. These modalities will be used regularly, so being able to read and protocol those studies will be very helpful.

10. Pay attention to different techniques and approaches from each attending. Early on in fellowship, you will find that there are many different ways EP procedures can be approached and performed. As an EP fellow, you will have the benefit of working with many different electrophysiologists who trained at different programs and even during different eras. By working with each attending and learning their different nuances to things such as how they select catheters for a particular procedure, how they close a device pocket, or how they perform an ablation with minimal or no fluoroscopy, you will gain experience in a wide range of different techniques and skills. As you progress through fellowship, pay attention to which equipment and strategies you prefer from each of the faculty members you work with, so by the time you graduate, you will be prepared with your own tailor-made armamentarium of skills to employ as a new practicing cardiac electrophysiologist. 

You are near the finish line of your training journey. You have made it this far and excelled in the process, or else you would not be here. Be proud and get excited! Keep these tips in mind as you begin or are about to begin your CCEP fellowship, and you will do great. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Gandolfo reports support from Boston Scientific and Medtronic for attending meetings and/or travel. Dr Lahiri reports no conflicts of interest regarding the content herein. 

Reference

1. Tung R, Mori S, Shivkumar K, eds. Atlas Interventional Electrophysiology: Atlas of Interventional Electrophysiology. Cardiotext Publishing; 2024.

Recommended Resources

• Burri H, Israel C, Deharo J. 2015. The EHRA Book of Pacemaker, ICD, and CRT Troubleshooting: Case-Based Learning With Multiple Choice Questions. Oxford University Press; 2015.

• Burri H, Johansen JB, Linker N, Theuns DA. The EHRA Book of Pacemaker, ICD and CRT Troubleshooting Vol. 2: Case-Based Learning With Multiple Choice Questions. Oxford University Press; 2022.

• Ellenbogen KA, Tung R, Frankel DS, Guha PK, Ho RT. Essential Concepts of Electrophysiology Through Case Studies: Intracardiac EGMs. Cardiotext Publishing; 2015.

• Murgatroyd FD. Handbook of Cardiac Electrophysiology: A Practical Guide to Invasive EP Studies and Catheter Ablation. Remedica Publishing; 2002.