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The Field of Cardiac EP: A Sociologist’s Perspective
Dear Readers,
In this editorial, I’m featuring an interview with Daniel A. Menchik, Associate Professor of Sociology from the University of Arizona, to discuss his new book, Managing Medical Authority, recently published by Princeton University Press. I had the pleasure of meeting Daniel many years ago when he was at the University of Chicago. It’s not common that sociologists would have an interest in the field of heart rhythm disorders. In this interview, we discuss what made cardiac electrophysiology such a revealing community for social scientists interested in the dynamics of careers, the management of authority, and the intersection of economic and professional activity.
The subjects in your book are mostly cardiologists and cardiac electrophysiologists. Please tell me a little bit more about what sociologists do and what made you interested in studying electrophysiologists.
Sociologists study peoples’ behavior alone and in groups. Much of my work is ethnographic, meaning that I do fieldwork — I study people in their everyday settings, especially in the interest of understanding the social organization of medical and other work. In doing this fieldwork, I aim to understand how members of the group see the world, but also analyze them from the perspective of a sociologist.
In terms of my interest, any subject becomes infinitely more interesting once one gets sufficiently close, and the open-mindedness of some electrophysiologists I met gave me the opportunity to see how interesting EP might be. Three moments stand out. First, I was invited to join a team on the inpatient wards that was headed by two different physicians, an electrophysiologist and a general cardiologist, and found that each of them differently managed their patients as well as the medical students, interns, and resident on the team. Their leadership styles fit with the way their work was organized — as a team vs a one-on-one encounter with patients — in ways that affected the group’s collaboration and work with patients. Second, I was interested in learning more about the diffusion of technology and medical practices, especially technologies that involve a hands-on approach to be learned in an apprentice-like manner. I described my interest in technology to an electrophysiologist, who told me, “Come study us, we’re rejecting technology all the time!” Who could decline? Finally, when I did start observing in the EP lab, I found a culture that was relatively self-contained, which gave me the confidence that I might come to understand it. I also realized that practices with patients were influenced by both events and people that were quite distant. It was exciting and methodologically innovative to work out ways to understand how these relationships, some of which are global in scope, shaped activities in the lab. Overall, EP appeared, and I think turned out to be, a perfect community for learning about fundamental social processes. For sociologists, this is a kind of Drosophila!
How did you start this project, and how long did it take?
I began my fieldwork in 2005. Sixteen years seems like a long time between beginning a study and getting published, but I studied 6 venues, from teams on the ward to guidelines meetings at the international conferences. To ask informed questions and begin to understand different schools of thought in EP, I had to learn an incredible amount — not only about differences in single-chamber pacemakers and subcutaneous defibrillators, but also about wide area circumferential ablation vs cryoballoon ablation.
In working on this parallel education, I found the EP community to be open and welcoming, inviting me to venues where I could understand the local and distant influences on their work. For my research, it didn’t hurt that labs have an observation window, letting me minimize the observer effect that fieldworkers are initially concerned about. Beyond its value for procedures, I felt having that window was reflective of one of the admirable dimensions of EP work — there is a strong norm of openness and sharing. It’s really no accident that the labs are formatted for others to observe and learn. At conferences as well as in board rooms and labs throughout the U.S. and France and Italy (and beyond), doctors, administrators, and industry reps both taught me and allowed me to observe and ask questions about their scholarship, technologies, and practices. During one industry meeting, I was even able to go transseptal with an ablation catheter, navigating to a pig’s left pulmonary vein. I am deeply grateful.
What were the main findings of your field work?
Generally, a key goal of ethnography is to bring a reader into a culture and simply reduce complexity. I also sought to represent EP work in a way that doesn’t reflect the kind of simplistic, imbalanced, and often-polemical accounts of medical (especially industry-associated) work we see in public-facing accounts. For sociologists, there were several key findings:
1. There is competition for status among EPs that determines who can sit in influential positions: as guidelines committee members, as principal investigators, as keynote speakers, and so on. This competition shapes who has the right to establish both the profession’s key problems of concern (such as atrial fibrillation), as well as its solutions (such as medications, devices, or ablation). This competition operates across venues that include the lab, hospital boardrooms, industry-sponsored events, and annual meetings of professional associations. Medical authority is maintained through this status competition, a process that helps establish what counts as up-to-date knowledge or best practice at any particular time, and which also serves to protect the profession’s authority by reinforcing the fact that it can meet public expectations.
2. There are relatively tight schools of thought, what sociologists call “invisible colleges,” among EPs that organize how they carry out procedures and make decisions about technology. A variety of objects are endorsed, used, and shared that serve to reinforce practices of one invisible college or another. These objects might be particular technologies that are more compatible with one approach (e.g., cryoballoon technology involved in pulmonary vein isolation). They might also be PowerPoint slides that are shared among colleagues, and describe a practice and contain citations that index membership in schools of thought.
3. There is stratification among EPs, organized in part by referral networks. These doctors may have been trained similarly, but as their careers have progressed, they have become differentiated in terms of having different patients, propensities for research, and set of work tasks. This stratification system functions to protect the field; those clinicians who prefer simpler cases get them and are successful, while referring more complex cases to those standard setters who value them for research (and status). In part because of the complexity of standard setters’ cases, and because they may learn about (and develop) technologies with industry, they are better apprised and able to use the most cutting-edge techniques. This interdependence, in theory, minimizes failures with the potential to hurt medicine’s authority, and provides cases to standard setters who can publicize advances in medicine.
What were the biggest surprises?
The first surprise was seeing an industry rep teaching an experienced physician at the bedside. I soon realized why it had to be this way, given the funding structure and social organization of post-fellowship training in EP. Yet, it still stood out. Seeing the rep in action as well as the efforts of the doctor to maintain an arm’s-length relationship was one impetus for me to observe non-hospital venues, to examine how practices inside the hospital were shaped by interactions in venues outside of it, which turned out to be a relatively innovative research practice among sociologists who study medicine and organizations.
In an early visit to one of these hands-on, industry-sponsored meetings, I encountered another puzzle that was crucial for my understanding of EP’s invisible colleges: what I came to refer to as contested anatomy. At the meeting, several respected EPs were teaching fellows and mid-career EPs about atrial fibrillation ablation. One said, off-handedly: “ablate the antrum, if you believe in it.” Later, during a live case at the annual Heart Rhythm meeting, a doctor referred in the same way to the macroscopic channels. Investigating these puzzles was crucial to my discovery about status competition and the shape of EP’s invisible colleges. But in those moments, I was perplexed: Who considers anatomy to be a matter of belief?
It’s true that electrophysiologists work closely with industry partners. We have industry representatives supporting most of our cardiac mapping and ablation cases and implantable device procedures. We also work closely with them as consultants to help create better ablation tools and implantable devices. This relationship is viewed by some as often being nefarious. What is your take on our relationship with industry?
My take is that, in contrast to the way that the relationship between physicians and industry is described (and caricatured), this relationship is considerably more complex and nuanced. As you well know, there’s a considerable amount of expertise shared by industry stakeholders. Most interestingly to me was that on many occasions, at the bedside and at industry meetings, I saw industry reps seek to not exploit but to protect the profession — for instance, in trying to prevent the use of their technologies by those who might misuse them and harm a patient. Critics sometimes point to doctors who have accepted considerable payment and refer to them as potentially damaging to medicine’s reputation. And certainly, that claim involves some truth. However, it is also true that these companies have a strong interest in the success of their technologies — the now-legendary shortcomings of the Sprint Fidelis lead loomed large in the imagination of the company reps I interviewed. So, I was somewhat surprised to see a potentially prosocial dimension of this complex relationship: industry’s closeness to physicians affords them the ability to deter bad apples with the potential of damaging medicine’s authority.
Do you have any advice to those who practice EP?
I really hesitate to offer advice to practicing EPs, but as a member of the public, I found myself feeling a certain ambivalence about the place of industry in medicine that you mention, and a somewhat unexpected appreciation of the role of hospital and practice policies. Being tied so closely to industry obviously has its strengths and weaknesses. The interdependence between EPs and industry is beneficial because it allows for opportunities to innovate. At the same time, patients might be concerned that the electrophysiologist isn’t acting in their best interest. To be sure, much of the industry-related interactions happen backstage and may exist at a level of abstraction that is difficult for the patient to appreciate. Further, it’s hard to regulate because of social influence that stems not directly from a company, but indirectly from a colleague on whom they may be dependent for patient referrals. For instance, I had some EPs tell me that referring physicians had explicitly said, “Implant a [Brand X] device in my patient, or I’ll refer her to someone who will.” One physician said that he deliberately rotated among companies.
I don’t know what the best mechanism is for maintaining an arm’s-length relationship. (Ultimately, influence may not matter for the patient; as a well-respected EP told me, “devices are like commodities: there’s wheat, corn, and pacemakers.”) But as long as organizations don’t prevent doctors from accessing those technologies that they feel are medically necessary for their patient, it is probably helpful for the legitimacy of EPs individually and collectively that institutions such as hospitals build in policies about industry, even if sometimes these rules seem overdone.
Do you think your findings would have been different had you studied other medical subspecialists, such as gynecologists, radiologists, etc.?
In some ways, yes. A key difference of cardiac electrophysiology with some other subfields is that patients reach them at the end of a referral chain, so you have the kind of social pressures mentioned above. But in other ways, there are multiple parallels with other subfields, ones which I tried to highlight in the book. As mentioned, I studied not only EPs but also cardiologists, hospitalists, and other general internists.
Are there studies of the social behavior of other physician groups?
Yes, not only in sociology, but also in allied fields. My inspiration was a sociological study of surgeons: Charles Bosk’s Forgive and Remember. It was a tour de force, and surgeons today continue to reinforce its timeliness. In anthropology, I’ve recently enjoyed the anthropologist Summerson Carr’s Scripting Addiction, and Jeremy Greene’s Prescribing by Numbers. There are many important studies. I’m also always inspired by reading (and rereading) works of literature, such as Franz Kafka’s A Country Doctor, A.J. Cronin’s The Citadel, and Sinclair Lewis’s Arrowsmith.
What do your sociology colleagues think of your book?
Time will tell! It’s early days; the book’s official publication date was November 30. In terms of (early) feedback, I received the profession’s Outstanding Dissertation Award in 2013, and I’m happy with the publication placement of my articles that use EP work as a case for understanding fundamental social processes. For books, it takes a long time to get any feedback — book reviews come out so slowly. I will be deep in my next project when the reviews come out in two years.
What else are you working on now and what are your future plans?
For the last few years, I’ve been very interested in the automation of expert labor. Sociologists tend to think about automation primarily in terms of the way labor is managed in factories, looking at the corresponding fallout for jobs and such. In contrast, experts have much more choice around what they use and how they use it, and their jobs are much more secure. For this new work, I have taken a piece out of my Managing Medical Authority project to study the adoption and use of medical robotics. I’ve watched some demonstrations of robotic procedures being performed at a distance — across states and even internationally. As I study the fascinating complications and opportunities of this kind of work, I would like to compare the work of doctors with that of other experts who use automated technologies.
Thanks for speaking with me today!
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Disclosures: Dr. Knight reports that he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AtriCure, Baylis Medical, Biosense Webster, BIOTRONIK, Boston Scientific, CVRx, Medtronic, Philips, and Sanofi. He has no equity or ownership in any of these companies.
