Innovation and Passion in Electrophysiology: Interview With Devi Nair, MD

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In this episode of The EP Edit podcast, we feature a discussion between Devi Nair, MD, and Edward J Schloss, MD. Dr Schloss talks with Dr Nair about her long and successful career in cardiac electrophysiology (EP).

This podcast episode is also available on Spotify and Apple Podcasts!

Edward J Schloss, MD: Hello, everyone. I want to thank EP Lab Digest for inviting me to host this podcast. We have a very special guest today, Dr Devi Nair. She is the director of cardiac electrophysiology at St Bernards Medical Center in Jonesboro, Arkansas. She also serves as the director of the Arrhythmia Research Group, which is a group that she founded in Jonesboro. I think you are in for a treat today, because Devi is very unique and she has a good story to tell. I have known Devi for several years. We had a really nice chat at Heart Rhythm 2023, and as we were having the chat, I realized this should be shared with everyone. So, I am hoping to recreate the chat here. Devi, welcome and thanks for joining us.
Devi Nair, MD: Thank you, Jay, for this invite and thank you, EP Lab Digest, for this opportunity.
Schloss: So, I looked at your Twitter/X bio, which really tells your story. It says, "EP director, mom, wife, Indian heritage, EP siblings, community advocate, arrhythmia fighter, zero fluoro, ICE fanatic, and electrocardiogram (ECG) hoarder." We could spend 15 minutes on each one of those. It is a remarkable bio, and hopefully we will touch on a lot of those as we go. Devi, I see you as a role model for a lot of people. You are a private doctor doing research, which I think a lot of people would love to have your skillset and do the things that you are doing. Tell me about your background and how you ended up choosing EP.
Nair: I grew up in South India. My parents were not in the medical profession, and I was the oldest of 3 children. I knew I wanted to be a physician. I thought I wanted to do cardiac surgery. I finished medical school and got into residency for surgery. Then, my dad passed away with cardiac arrest from ventricular fibrillation. He was pretty young, and it really shook me. It was one of those moments where I felt like I had to revisit what I wanted to do with my career and with my life.
I moved to Lancaster, Pennsylvania, with my husband, who is an information technology professional, and worked at Lancaster General Hospital with Seth Worley. During that time, I got to know what EP was about. However, I really got to know EP in New York when I did my medicine residency. Jonathan Steinberg and his team were the EP group there at that time. I felt like that is what I wanted to do, and it just meant more to me. At that point, I was so young. I was thinking I was going to be a sudden cardiac arrest fighter. That is what got me into EP—thinking about what I could do to prevent sudden death.
Schloss: So really, this whole time you were thinking about your father.
Nair: Yes, and talking about EP siblings, my younger brother, who is 2 years younger, became an interventional cardiologist. I pulled him into EP, too, so he is an electrophysiologist as well now. For both of us, it was traumatizing for us to lose our dad so young. EP was the solace. We were trying to find answers, and that is what got us into EP, which has now turned into something way more than just finding strength.
Schloss: You brought up your brother, which there was a remarkable picture that ended up on Twitter/X—I will let you describe it—at this last Heart Rhythm Society (HRS) meeting. Describe to me what happened.
Nair: Yes, both of us attended Heart Rhythm this year. Both of us had clinical work that we were presenting and we were each doing a moderated poster. This year, we had moderated poster sessions that were back to back, so if you look from the side, both of us were presenting moderated posters simultaneously, facing each other back to back. Somebody captured a picture and I thought it was incredible, and we were so thankful. I have to say, I probably saw my mom shed a tear when she saw that.
Schloss: I think I did, yes.
Nair: It was just remarkable.
Schloss: I think you said something about remarkable that you had each other's back. It was really something else.
Nair: It truly was. The work that he was presenting was on some remote mapping capabilities that we were doing because since COVID, it has been really hard for him to do complex ablations. We piloted this project where I was doing mapping remotely through this software. I would map for him with the mapper at night.
Schloss: Amazing.
Nair: Yes, so we collected this data, and that is what he was presenting. I was so proud of him and he was proud of me.
Schloss: So, you came out of practice with great training and great mentors, and you are highly skilled. Now you find yourself in Jonesboro, Arkansas. How did you land in Jonesboro and what was the EP situation when you got there?
Nair: I trained at the MetroHealth Campus at Case Western, and I was in my first year of EP fellowship when I met Franklin Roosevelt (Rosey) Gilliam. He was one of the clinical electrophysiologists. He left Duke to come down to Jonesboro, and was practicing EP there and was looking for a partner who could come and start an atrial fibrillation (AF) ablation program and complex ablation program. As an EP fellow, I thought, "What an incredible opportunity!" I felt like it would be a great opportunity to start a brand-new program, but I was not sure about Arkansas. So, I came to the town and met the group. It was a much smaller group at that time, but it was a phenomenal group that had a vision. They had a vision of wanting to get better and be upfront with technology and take care of the community. It was such a great group with incredible physicians who were talented and looking for a partner who could help them take it to the next level. I thought, "Why not give it a try?" I was the first female to join the group.
Schloss: How many EPs were there when you arrived, Devi?
Nair: Just Rosey, who was doing mainly devices.
Schloss: You were just the second one.
Nair: Yes, some right-sided ablations. So, I was joining to mainly start left-sided ablations, VTs, AF ablation, and some structural work. That was my passion, too. I wanted to do more left atrial ablations and complex ablations. So, that is what brought me to Arkansas, to start this program.
Schloss: How long ago was that?
Nair: I moved here in 2011.
Schloss: How quickly did it build and where are you now?
Nair: We have gone through a lot of changes. Rosey moved on back to North Carolina for his family in 2013, so after 2 years, I was a single EP here for a little while. Then we went through a couple electrophysiologists, trying to find the right partner to be a part of this community. Now we are at 3 electrophysiologists. The program and group now has about 25 of us altogether with a lot more room to grow, so we are definitely looking for new electrophysiologists and the right partners who want to be in a location like this.
This is a large community. There are about 70,000 patients in northeast Arkansas, south of Missouri. The town is very small, but there is such a lack of advanced health care and lack of access to care. So, to be able to come to a place like this is a great opportunity. That is one thing I always encourage younger faculty as they are looking for jobs. Stop only looking at big metropolitan cities. Look at these smaller communities where you can make a difference. Every day, I try to make a difference.
Schloss: But I think a lot of young doctors, and I have been one of these people, when you come out, you had Rosey who did not do left-sided ablation, so you were kind of on your own, right? You were in a place that had never worked on the left side. You are brand new out of fellowship. Was that intimidating?
Nair: Absolutely. I mean, every day is intimidating. The year 2011 was intimidating, and so is 2023, right?
Schloss: Yes.
Nair: But having said that, I think that is where having mentors comes in. They do not even have to be in your hospital, but having mentors who are always available. I had great mentors. For AF, I trained a little under Andrea Natale, so I could call him anytime. I have called Eric Prystowsky live from the lab asking him questions about complex supraventricular tachycardias (SVTs). I have called Melvin Scheinman. I had no trouble calling people if I needed help. I knew when I needed help, so I would call. However, I also had a great group that worked with me, including administration that understood what I wanted and that I needed certain technologies to make this safe. This is not something one can just come in and build—you need the right tools and they needed to invest in this. The group was invested. The administration was invested. The lab trained with me. I remember my first AF ablation in April 2012. It was April 15, and I had started in October 2011, and it took me about 6 months. I started with simple ablations and right-sided ablations. I then did some transseptals and some left-sided ablations, and I made sure they were ready to do RF ablations before venturing into AF.
Schloss: Can you frame that as advice for people who are in the same situation? How much did you initially bite off and chew, and how do you work your way up?
Nair: I am not saying you only can perform easy cases in the beginning. You have to do your due diligence, but my motto has always been that there is always another day to fight the battle. If you do not know, don't do harm, stop, and you can always come back. In the beginning, taking on flutters and SVTs and pathways—believe me, there was enough of that over here. It was an arrhythmia-naïve, ablation-naïve community, so I had no issues finding any of that. That gave my lab staff the confidence because that was new to them. The technology, the intracardiac echocardiography, whether it was a mapping system, all of that was new here. My team got confident in what it was, so they felt like I had their back, and that means that they have my back.
When we came to the point where we got to AF ablation, I remember bringing my team to Cleveland where I trained, to Metro, and making sure each one of them shadowed their counterpart where I trained, saying, "You are going to be this person on Monday, so just watch. This is what you are going to do. Just replicate it." I am extremely thankful to Bill Lewis, who is still there at Metro, and Ohad Ziv, who is the EP director there now, for letting me do that because it speaks to their mentorship. They wanted me to succeed.
We came back that Monday, and I still remember my first day of ablation alone. It was a breeze. So, I always tell people, "Just think it through, take your steps. Your lab team always has your back if you have their back." From then on, we are now a much bigger program. We have 3 EP labs. Two of them are dedicated EP labs, with the third one being a hybrid lab. We have an external outreach lab, and it is a 5 days a week, full-time EP service now.
Schloss: Devi, did you have to market yourself or do patients come to you? Was this from partners’ pent-up demand and you started having patients sent your way, or did you have to work to find them?
Nair: No, I had to work to find them, because even for my partners, they knew they wanted ablation, but they did not know what all I could do. The first 2-3 years, I spent at least one day a week meeting referring physicians and doing talks. Sometimes it was patient-directed talks, so I would go to the community center and talk to patients about AF, what it means and what we can do, or sometimes it was about devices. I did the same thing for referring doctors, and I met them on a regular basis.
I always answered phone calls. I was that physician that always returned a phone call and always called the physician after I did a case. All those things that we teach our new faculty who come out. I might be a little more slacking now on that part, but I know that they know how to get a hold of me if they need to. For the first 3-4 years, I was on it. It takes a lot of hard work, but it pays eventually. You cannot do a good job if you cannot educate your referring doctors. They have to understand what you are doing.
Schloss: How busy clinically are you now? What is a typical day like for you?
Nair: I am in the lab 4 days a week, and I am in clinic one day a week. I have an incredible group of nurse practitioners (NPs) who work with me under my guidance. We usually work as a team, and that is in addition to my partners. So, when I am in the lab, usually I will have 2 labs going simultaneously that I bounce back and forth to. The lab stays pretty busy. I also do consults on the days I am in the lab, and then I will have an NP in the lab and also on the floors who is helping me. Similarly, when I am in clinic, I have NPs who help see patients, get them prepared, and get them ready. It is a great way to practice EP and do what I love, and not have to worry about all the other stuff.
Schloss: You have obviously built an amazing clinical service, but that is not at all. At this year's HRS, your group, and you can tell me about the rest of the folks that work with you, presented 16 posters and gave 18 talks. I suspect that is more than most university EP groups! How have you been able to do this?
Nair: Even though I came to EP because of what happened with my dad, once I started to understand EP, I found that the beauty of EP is innovation. That is my passion—new technologies and innovation. I have always wanted to be in front of technology. I am also very driven with keeping quality care. I started the program, so I wanted to make sure I kept the quality, which means I had to keep my own data. I did not have a research group or research entity here. So, after the first 3 years of being here and establishing a practice and setting my base, I started a research group, which has evolved into what is now known as the Arrhythmia Research Group. We started off with some industry and sponsored trials and built our platform, but we took that group that did industry-based or sponsor-based trials and used that to build our own quality products, so we actually maintain our own outcomes and our own data.
St Bernards Medical Center has an internal medicine and family medicine residency program. We do not have a cardiology fellowship. So, for our internal medicine residents who are passionate about cardiology, the requisite to join the Arrhythmia Research Group is they have to rotate with me. They interview, but they must show their passion. You cannot just come in and be a part of it. It is a little bit stricter to get in, but once they are part of it, this is my way of mentoring. I do not have fellows, but this is my way of giving back. I try to mentor my residents who want to go into cardiology and try to guide them to go into EP if possible, but I am biased.
Schloss: Your residents are presenting at major national meetings. These are medical residents in a community program in Arkansas who are presenting at HRS and Western AF. They are remarkable people. I have had a chance to meet them.
Nair: They are very hardworking. They work on all our data. We meet on a monthly basis. We come up with ideas. I give them guidance. They maintain our data, so our clinical work becomes better because we keep our own outcomes and we publish our outcomes. The majority is that way. Sometimes we will do new and innovative stuff, and they will present it. I also have pre-med students and medical students. Arkansas has the NYIT College of Osteopathic Medicine-Arkansas, and we have a bunch of pre-med students in the group as well. It is incredible to not just mentor them, but also teach the residents how to mentor the pre-med students. It is giving back, so it is good to see them learn how to mentor as well. It has worked really well.
Schloss: Now, none of this works unless you have good relations with the hospital and industry. I believe all those relations are fraught with potential conflicts. Navigating through those conflicts while maintaining high-quality patient care in an ethical manner is always a challenge. Tell me how you have navigated those waters.
Nair: You are right, it is a fine line when it comes to having a relationship with industry. However, I believe in the field of EP where we are constantly innovating, and as a physician who is interested in innovative technologies and being at the forefront of new technology, I have to partner with industry. There is no other way for me to have this kind of technology come to this town in northeast Arkansas. They would not see this for years otherwise. So, that was the number one reason that I started the research group, is to bring new technology to where I am and give my community access to that. From then on, I started realizing, "When I do this, I can learn from it, but I also have to be careful." It is easy to have conflicts and bias, whether it is financial or nonfinancial, so that is something you learn slowly.
I have had a very unbiased relationship with almost every industry partner. All I care about is speed and innovation that is going to make a difference. But also, it is important not to interfere with the work or research I do. If I want to collect data, it is my data. I have had issues where if I had a problem with work that is being done, and I had access to senior people in industry who I could lodge my complaint to and they would listen. I do not think I could live without it, because what I am passionate about is the new innovations. We are strongly tied to industry when it comes to innovating.
Schloss: Yes, I totally echo your responses. If you are in our field and you want to advance the field, you have to partner with industry. There is no other way. You are not going to invent a cardiac device in your garage. Devi, you are aware that EP is grossly underrepresented by women. Stacey Howell wrote an article¹ in Heart Rhythm about a year ago that said in the field of EP, of the electrophysiologists who do invasive procedures, only 5% are women. This is dramatically underrepresented, it is well lower than fields like interventional cardiology, which you might expect to be even less representative. Why do you think women are not joining EP and what can we do to change that?
Nair: That is a great question. When I meet cardiology fellows who are women, who say, "I do not know whether I want to do EP," I always ask, "What about EP does not attract you?" I have heard, "I do not have a mentor," or "I am really worried about radiation exposure. I am worried about the time I have to be in the lab away from my family. I am worried about having a family." These are things that always come up.
The answer that I almost always give is, "Listen, I am married. I am a mom. I was pregnant with my younger son when I was a second-year EP fellow, and he is now 12. They have done incredibly well. I have a great spouse and family that gets how important this is for me. You have to have a supportive family, but it is possible.
You talked about my Twitter page about zero fluoroscopy. That is what got me passionate about reducing fluoroscopy. When I did my fellowship, we used tons of fluoroscopy, but since 2014, I have not worn lead or used fluoroscopy for most of my ablations. In 99% of ablations, we do not. That did not come overnight. So, I do not think any of that should be an excuse anymore.
I tell them, "You can always reach out, but it does not have to be female mentors. There are a lot of male mentors." You are a great example. I have known you for many years. So, these are some of the things I hear about. I have been with HRS for many years, but a few years ago I joined as a volunteer in the subcommittee group, and I was the vice chair and chair for the subcommittee group. We created this mentor app where you could sign up and be partnered with a mentor. I thought it was a great idea where you could just choose who you want, and they could be miles away. I could choose Jodie Hurwitz as my mentor if I wanted to, and she could say yes or no and help mentor me through my challenges.
Similarly, there are some recent programs that we are looking at for medical students. We do not want to wait until they get to cardiology fellowship before we talk EP. We want to start talking to them about EP in medical school, maybe even pre-med or internal medicine residency, to try getting to that pipeline early before they start funneling out, and maybe dissolve the fathoms about EP that many people have.
Schloss: So, one of the things I would like to close with is that I know you have a life outside of EP, because I have seen your garden in pictures. Tell me about work-life balance, because it is difficult to imagine you could do all the things you just described and still have work-life balance.
Nair: Work-life balance is a hard subject. I do have a very supportive family, so I could not do what I do without my husband, Manu, and my kids who understand and have grown up to be incredible young men. I know my lab days are going to be long, so I spend mornings with my family. I do not start my lab until 8:00 AM. My family understands it might be late when I get home.
They know that on a clinic day I am going to be home early, so we plan things that way. I try to be part of most of my kids' activities, but they understand that I cannot be at everything, so they prioritize. For me, my work family is also my family, so they know my kids and it has worked out.
Schloss: Didn’t you work out a deal with your hospital about weekends?
Nair: Yes, so I work Monday through Friday, but on the weekends, I am not in the lab. I do not have as much call. Even though I am part of this big group, because we have pretty long days in the EP lab, I do not really do much weekend call, which helps me spend time with family, but also if I have to travel for meetings and conferences, which I do quite a bit, I get to use that time.
Schloss: Yes. Well, Devi, I think we have covered it all. Is there anything else you would like to talk about?
Nair: No, I think you have put my whole life into 30 minutes!
Schloss: Yours is an amazing story that I think there are many people that can draw from different elements of what you can do, but I am not sure there is anybody who be Devi Nair. It is really impressive what you have done, and I encourage you to keep it up, and I look forward to seeing you again.
Nair: Thank you, Jay. You have been super kind, and thank you again for having me come on this podcast.
Reference

1. Howell SJ, Simpson T, Atkinson T, Pellegrini CN, Nazer B. Temporal and geographical trends in women operators of electrophysiology procedures in the United States. Heart Rhythm. 2022;19,(5):P807-811. doi:10.1016/j.hrthm.2022.02.015

The transcripts have been edited for clarity and length.