The Importance of Choosing Cardiac Electrophysiology as a Career: Thoughts on the EP Fellow Shortage

A recent report from the National Resident Matching Program (NRMP)¹ showed that approximately 40% of the 130 clinical cardiac electrophysiology fellowship positions in the U.S. remain unfilled. According to the same report, 99% of cardiovascular disease fellowship positions were filled. These numbers are independent of the “prestigious” status of a given program. 

Over the last 5 years, there has been a decline in the number of fellows choosing EP for advanced training.² There is no dearth of exceptional faculty, pioneers, or scientists to inspire those to pursue a career in EP. Electrophysiological technologies are rapidly advancing. The curative procedures performed in this field have a meaningful impact on patients’ quality and quantity of life. There has been exponential growth in cardio-genetics, and healthcare economics offer high reimbursements. With all of these positive attributes, why is the EP field unable to recruit fellows? 

As someone who has undergone the requisite training as well as had several years of experience, here are a few points to ponder as we address this crisis.

Early Exposure to EP 

Some say that it takes a different kind of person to do EP. However, it is not the person that makes it different ­­­— the EP field itself is unique. The medical profession in general trains us to think in terms of biology or physiology — we are not used to thinking in terms of force time constant, voltages, or thresholds when treating a patient. In EP, one has to approach clinical medicine from the perspective of engineering and mathematic principles. Exposing second- and third-year residents and first-year cardiology fellows to the EP field allows enough time for them to comprehend this analytical subspecialty. If we wait for second- and third-year cardiology fellows to enter the EP lab, we have lost the opportunity of early exposure. 

Role of Mentors

With the EP field being relatively young, the number of mentors is potentially smaller and less diverse. While available mentors are of exceptional caliber, we need more of them to attract candidates from all backgrounds. Efforts to demystify this field for trainees is much needed, and teaching needs to be brought to the level of residents and fellows as well. Meaningful and realistic mentor-mentee programs with inclusion of women and minorities also need to be implemented. 

A Complex Field

Invasive fields are based on direct visualization via fluoroscopy or ultrasound guidance. Cardiac electrophysiology is especially challenging in this regard because of the integration of various modalities that electrophysiologists use to diagnose and treat, such as intracardiac echocardiography (ICE), fluoroscopy, three-dimensional mapping systems, intracardiac EGMs, and surface EKGs. Tasks have to be managed while taking care of the patient and communicating with staff. The long procedures can lead to sensory overload and fatigue. To encourage efficiency, reduce stress, and promote optimal outcomes, changes in practice have to be considered, which will translate into making EP more appealing to those on the fence. This can be achieved by the following steps:

• Protect lab time (eg, no elective calls during procedure time). 
• Provide support with reduced EP call burden (eg, temp wires, routine updates, and non-urgent calls, etc., need to be delegated). 
• Provide support with advanced practice providers.

Work-Family Balance

Physician burnout is a real issue in medicine.³ When fellows consider life as an electrophysiologist, they might worry that work-family balance could become lopsided. Evolving technologies often affect existing skill sets and cause long work hours, requiring personal sacrifices that might not entice fellows to join this field. We need to redefine the work structure. 

For example, cases requiring anesthesia are typically booked for early starts in the day. The unpredictability of emergency cases during and at the end of the day (depending on staff and lab availability), as well as on-call requirements, can make achieving work-family balance difficult. What about kids’ activities and quality time with family? One solution could be to redefine the full work week as 4 days per week, which leaves more days for family and less room for burnout.

Considerations for Women in EP

Currently, around 7-10% of all electrophysiologists are women. In 2018, this increased to 19% for first-year EP fellows.⁴ It is important to note that childbearing age overlaps with the training period. Radiation exposure to the fetus is a valid concern; however, wearing double lead is not always the best or most comfortable option. Possible improvements can be made in the following areas:

• Making residents and fellows aware of zero fluoroscopy procedures is imperative. 
• Training EP fellows to use ICE with 3D mapping systems needs to be a priority. 
• Women should have protected time during pregnancy during which they can do research and/or cover clinics in order to avoid radiation exposure and the need to stand for long hours. 
• As such, if women are exempted from procedures during pregnancy, adequate training and expertise in a variety of procedures would need to be ensured. One consideration would be to set up transparent goals and competency expectations, and provide extra time beyond the regular 2 years of fellowship for these women as needed.
• Private lactation areas with a refrigerator not only for physicians, but also for the staff, should be implemented. These should be built closer to the procedural areas (having to walk in-between procedures to a common locker area where there is a staff refrigerator is unacceptable). 
• Engagement at grassroots is important. Currently, industry-sponsored programs do a good job by catering to fellows, although most of them might have already committed to EP. In order to tap residents and first-year fellows, we should consider regional Women in EP (WIEP) chapters, similar to ACCWIC initiatives. These chapters meet yearly with an open invitation to residents and fellows, with goals of mentorship, networking, and education (presentations by residents/fellows). 
• Social media engagement should be expanded to reach out to a larger audience.

Reduced Training Time

The present pathway to training includes 3 years of general cardiology followed by 2 years of EP training. One suggested change is to reduce the training period of general cardiology to 2.5 years for those who will pursue EP training. The last 6 months of general cardiology training could be used to focus on advanced congestive heart failure, CRT/ICD management, as well as ICE training. This could allow for 18 months of EP fellowship due to this increased head start. Therefore, the total training time could be reduced to 4 years. 

In addition, EP training could be divided into device and ablation paths, with some overlap. This will allow opportunities for niche and focused training (given the enormous expansion in both areas of EP) while reducing the training period.

A Stronger Bridge

Private and academic sectors need to communicate with each other with mutual respect and understanding. A bridge across different organizations will enable early exposure to the field. 

For example, we should do away with rigid walls between academia and private practice. The residents and fellows who train at academic institutions do not have any idea about private practice and healthcare economics. Carving out time for the senior residents and fellows to do an elective at a private practice institution, as well as inviting both academic and private practice speakers to regional meetings, are just a few ideas. This enables trainees to better understand their options, customize their future, and plan it early enough to suit their lifestyle. Lastly, physician mentors should interact with trainees at national and regional meetings to help with increased engagement and recruitment. 

Summary

We owe it to our patients and to the field to address this potential workforce deficit. It is imperative in order to carry on the pioneering work of leaders and committed teachers such as Dr. Fred Morady (my mentor). 

Disclosures: Dr. Tamirisa has no conflicts of interest to report regarding the content herein.

1. Fellowship Match Data and Reports. National Resident Matching Program. Available at http://www.nrmp.org/fellowship-match-data/. Accessed January 4, 2020.
2. Kowey PR, Robinson VM, Esberg D. Electrophysiology training in crisis. Fellowship numbers are down and reforms are needed. Cardiology Today. Published November 2019. Available at https://bit.ly/35Tvuxz. Accessed January 4, 2020.
3. Kane L. Medscape National Physician Burnout, Depression & Suicide Report 2019. Medscape. Published January 16, 2019. Available at https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#8. Accessed January 4, 2020.
4. Resident & Fellow Workforce Data. American Board of Internal Medicine. Published November 13, 2018. Available at https://www.abim.org/about/statistics-data/resident-fellow-workforce-data/first-year-fellows-by-subspecialty. Accessed January 4, 2020.