Transitioning From Fellowship to Practice

Interview by Jodie Elrod

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates. 

In this feature interview, EP Lab Digest speaks with Mark Lee, MD, and Jashdeep Dhoot, MD, with Memorial Cardiology Medical Group in Long Beach, California.  

Thinking back to your EP fellowship, what do you think was the most helpful aspect in preparing you to start your own practice? 
Mark Lee, MD: Interestingly, I did not have any lead extraction exposure during fellowship. I remember any patient who needed lead extractions was referred to a high-volume operator out of state. As fellows, we did not follow these patients to completion. So, my initial experience was that I had zero experience. When I began developing an interest in lead extraction, I looked for a mentor who could teach me these skills when I joined the practice.
Jashdeep Dhoot, MD: I had kind of the opposite experience as Mark when it came to lead extraction training. During my fellowship, I was at a center in Kansas City with a large lead extraction program and I received a lot of hands-on training. Even then, I sought out cases because lead extraction is a relatively rare procedure compared to other things that we do as EP physicians. So, even in a busy center, to get the adequate training and clinical competency, I really had to chase down cases.

What do you wish you had more of in your fellowship to prepare you for your own practice? 
Lee: Even if a program does not have or perform lead extractions, it is important for fellows to receive didactics related to proper implant technique, indications for extraction, and an understanding of the risks and benefits related to the procedure. Looking back, didactic sessions from the high-volume operator that we referred patients to during fellowship, perhaps in the form of a visiting professorship, would have been valuable for us.
Dhoot: Believe it or not, I wish I had a little more clinic time during EP fellowship. It was a very hands-on fellowship. We learned a lot of technical skills in the lab, but I did do some clinic. Initially, I thought that it was not necessary. We did a lot of clinic and general cardiology training. But when I did clinic, I realized there was a lot to learn. For example, how do you properly counsel patients? How do you consent them? How do you get them to understand the complexities of procedures such as lead extraction in a short amount of time and be able to do it efficiently? I thought that was more valuable than I initially appreciated, so I would encourage fellows to do as much clinic as they can while in fellowship.

If you were setting up the ideal lead extraction fellowship, what would it look like? 
Lee: First, you must be involved in many cases, so a high-volume center will be really beneficial. Didactics need to be a part of the curriculum. I also think it is important for fellows to be exposed to both the laser and mechanical tools to see the pros and cons of each of the systems. I am a true believer in the tandem approach, so going to a center where you can learn both the superior and femoral techniques, including the ability to snare leads, is critical. A means to follow up patients in the clinic setting is critical as well. I feel like fellows are great at being involved in inpatient acute care, but we really do not get exposure to aftercare, when patients in follow-up come in a week or two later. So, that is really important. Also, an ideal fellowship would include a close involvement with the cardiothoracic (CT) surgeons to see their approach and what they are looking for as they back up these cases.
Dhoot: I agree with Mark. The most important thing is volume. Lead extraction is a relatively rare procedure. The Heart Rhythm Society (HRS)/American College of Cardiology training recommendations recommend a minimum of 30 lead extraction procedures to maintain clinical competence coming out of training, and that is hard to find. So, you need a program that has a lot of volume, with ideally more than one operator. Generally, lead extraction tends to fall to one position. If you find a program where there is more than one operator, it allows for exposure to more than one approach. Having exposure with both the different sets of tools that are used, including laser and mechanical extraction tools, would be great.

Do you have a mentor? If so, do you find that valuable? 
Lee: Because I learned about lead extraction during practice, having a mentor was extremely valuable to me. I do not think I would have been able to continue the program that has been established here without having that sort of guidance. Dr Tobias was my mentor. By the time I joined, he had been performing lead extractions for close to 30 years. He created an environment for me to learn. It was like going through the ideal fellowship as an attending, so it was an incredible experience for me. He retired last year, so I am fortunate to now have Dr Dhoot to serve as a sounding board and perform cases together. These are complex cases, so Dr Dhoot and I typically co-operate in all our cases nowadays.
Dhoot: Dr Tobias was as a mentor for me as well, although with a slightly different approach. Dr Tobias was involved in my general cardiology fellowship training, and that was my first exposure to lead extraction. We received hands-on experience there and it helped me make the decision to go into EP and do this procedure. For the first 6 years out of training, I actually was not involved in a lead extraction program—it was not until I joined Mark this year. I am now learning from Mark on some of the newer techniques, so it is great to collaborate with him. 

How do you hone your skills? 
Lee: That is an important question, because lead extractions are generally safe but can have some catastrophic complications. I am always thinking about lead extractions on a day-to-day basis, including how I can get better and how to make it safer. I try to attend local symposiums on lead extraction whenever they are in the area. Earlier this year, I went to Utah to observe Dr Roger Freedman's tandem approach using the needle's eye snare, and that was really valuable to me. After the trip, it has become one of our favorite tools! We really depend on it. So, that was an amazing course. Even as an attending, I think it is important to be humble about the fact that there is always more to learn. Day to day, with any new implant I do, I always have extraction in the back of my mind. Even when I am getting access for a fresh implant, I am mindful about the angle of my entry of the needle, where I place my leads, and how much slack I give the leads. This includes learning about all the new leads coming out from the different vendors, what the leads composed of are, and what type of materials are they made up of. That is how I keep up to date, and it is important to be mindful of it, even on a fresh implant.
Dhoot: Attending lead management courses and symposiums are helpful. I also stay up to date on the literature. There is always a new technique coming out. Never get comfortable in your approach, as usually there is at least something you can add to that procedure down the road. Staying up to date on the literature is really helpful to maintain skills and modern, contemporary techniques.

What is your advice to current EP fellows? What should they focus on, learn more of, etc? 
Lee: I believe you first need to have a passion for lead extraction, because compared to other procedures, I truly think that lead extraction is more of a lifestyle. You are going to have difficult patients and difficult conversations with families, so you will need to be prepared for that. Lead extractions also often occur at the least convenient times. There will always be an urgent infection case during your busiest week, and you will need to rearrange your schedule. Sometimes these are very difficult cases, and my schedule does not align with Dr Dhoot's, so we have to coordinate to ensure both of us are available. So, if you are still interested after all of that, then you need to understand how to be a better implanter. I think a good practice is anytime you see a chest x-ray with a pacing lead or implantable cardioverter-defibrillator (ICD) lead, even if the patient does not need an extraction, look at the features of that x-ray and ask yourself, "if I were to extract this lead, what would make this an easier versus difficult extraction? What are some of the hurdles to overcome?" If you have that mindset, it will prepare you for these different scenarios.
Dhoot: It can also be difficult to find a job or position where you can perform lead extraction. These are relative rare procedures, and they are oftentimes done at larger referral centers. So, if you know you want to do lead extraction, it is important to start making connections in the region or country where you want to practice. Find hospitals that either are already doing extraction, potentially doing them, or would be good candidates, then find people in that area and start promoting yourself and getting your CV out there. Talk to physicians and company reps in the area, and see where you potentially could land and have the opportunity to do lead extraction. Again, it is not going to be available to you at every single job position. So, getting that ball rolling while you are in fellowship is important.

What is your advice to new EP fellowship graduates as they transition to a new facility and start their own practice? 
Lee: It depends on how experienced you are with exposure to lead extraction as a fellow. If you have a lot of experience, then you already have a head start, so maybe you do not necessarily need to have an experienced mentor at a program and you could just build your own program from scratch. Regardless, you will need the support of your hospital. Early on, I would talk to the hospital administrators about creating a team. It is not just about the operator; you need to have supportive CT surgeons, a referral base, and infectious disease doctors who are willing to follow the patients throughout their course, which can sometimes be 2-4 weeks. Therefore, you are going to need a lot of personnel, support, and equipment, so having conversations early on and getting support from all the specialists is important for creating a new program.
Dhoot: Exactly. Also, finding a local mentor is important. It is difficult to do lead extraction in isolation, so you will need a colleague to bounce ideas off of and help scrub in with you during these cases. When finding someone in your own medical group or another local physician, you may sometimes have to make some accommodations to collaborate and get the program off the ground.

Specifically, in regard to lead extraction, what would have been helpful in fellowship to prepare you to start your own practice? 
Lee: Since I had no exposure, I really did not know what lead extraction entailed. So, having some sort of didactic series throughout the year, whether or not the fellowship program has a lead extraction program, is really important. Even if it does not have a program, there are certainly a lot of opportunities for attendings to teach fellows the proper implant technique so that the patient will not have a mechanical issue for extraction in the future. Obviously, infection is something that you cannot predict. 
As a fellow, it was my experience that instead of removing a pacemaker lead for an ICD upgrade, we retained that right ventricular pacer lead and added an ICD lead right next to it. So, I thought that was commonplace. When I started practice, I observed Dr Tobias removing all those pacer leads that were not important and upgrading to make it a cleaner, MRI-compatible solution. It was important to have that understanding that there is a cleaner way of doing things, and from my perspective, if I did not have exposure to the lead extraction practice, I would have continued that route of retaining leads and keeping hardware inside the patient. 
Dhoot: Similarly, I think what would have been helpful in fellowship would have been to get exposure to both laser and rotational mechanical extraction tools. You usually get exposure to one or the other. For me, it was laser. In fellowship, I would advise fellows to seek out exposure to the modality that you are not seeing. That might include attending symposiums or courses, or shadowing another doctor in the area to get exposure to both methods.

What do you wish you had learned about lead extraction in your fellowship? 
Lee: For me, it was just not being exposed to lead extraction at all. I did not even know what the tools looked like. Whether it was laser or mechanical, I had no concept of what the procedure entailed. So, even a simple didactic would be really helpful. Also, exposure to all the different tools available is truly important. Some centers only do a superior approach, and some centers only do femoral. Since lead extraction is such a potentially difficult procedure, it is important to have all the skillsets available.
Dhoot: The one thing technique that I did not get exposure to in fellowship that I found incredibly valuable and that Mark taught me a lot about was snaring from below. Using the needle's eye snare has made the procedure a lot smoother and easier to get leads out. I wish I had received that exposure in fellowship. Now that I have, I find it incredibly valuable. So, if there is some technique that is commonly being used but you are not getting exposed to it, seek it out while in fellowship.

What would be your advice to current EP fellows if they are interested in doing lead extractions in their practice? 
Lee: Besides finding a mentor, see what is available at the institution that you are going to. If it is already an established program, it is going to be much easier, but you may be bringing in a skillset that the existing institution does not know about. Lead extraction typically has an existing workflow. So, if you are going to introduce something new, it requires training and inservices to the staff so they are aware of these newer techniques. In our practice, we have been doing lead extraction a certain way under Dr Tobias for 30 years. So, when we are trying to introduce newer techniques to our program such as the needle's eye snare, it takes some in-service and training for the personnel to learn these new techniques. Therefore, there is always training involved. I am sure there will be other beneficial tools moving forward as well. It is important to keep both an open mind and open lines of communication so that everybody is on the same page.
Dhoot: Agreed, find a mentor in the area. Even if you are starting a program from scratch and you are going to be the main operator, you will still need someone to collaborate with and ideally co-scrub with you, so identify that person. It may be someone at your institution that you are joining or someone in the region, but identify someone that you can bounce the ideas off.

What advice would you give new graduates who want to do lead extraction in a new facility that currently does not have a lead extraction practice? 
Lee: Get the hospital’s support. Talk to the administrator about your vision for a lead extraction program. Also, talk to your cardiology referral base and see if you have enough personnel to even create a program. Do you have a good infectious disease program? Do you have a good radiology program, for example? We like to do computed tomography scans on patients to assess the lead core and assess if the leads are embedded or perforated, and it takes a certain skillset to interpret these specialized studies in a way that is pertinent for an EP. So, there are a lot of moving parts. First, you must see if there is even a need for it. Once you have developed a program, the referral base seems to come. One of my fears was that the lead extraction volume would dwindle now that we are in the age of leadless devices. However, we have found that once you have a busy program, you will find referrals and indications that you did not think about before. So, talk with the referral base and the existing cardiologists, and see what type of need there is and how much referral outsourcing is being done currently. That way, you can see if it is worthwhile building a program.
Dhoot: When starting a new extraction in a new facility, there are 3 things to keep in mind. First, ensure you have sufficient volume. The HRS guidelines suggest extraction of 20 leads per year to maintain competency, and so you will need sufficient volume to achieve that. Second, identify somebody that can scrub these cases with you. I think the expectation and standard of care nowadays is to have 2 operators since there is a lot of work to be done from both the groin and top of the pocket. So, whether that is 2 Eps, one EP and a surgeon, one EP and a fellow, or 2 surgeons, you should identify a colleague that can work with you on these procedures. Finally, ensure you have adequate CT surgery backup. It is a lot to ask of a busy cardiac surgeon to be available in the room on a moment's notice when doing these procedures. Make sure you identify that person ahead of time before starting the program.

Have you had the opportunity to participate in any training activities post-fellowship as an attending? What was your experience? How has it affected your current practice? 
Lee: Yes, I have had a few opportunities over the past 7 years as an attending. HRS has great programs, even simulators where you can handle some of the tools. Our local area holds annual symposiums, so I try to attend those as frequently as possible. Also, I attend cases elsewhere to observe others with a skillset that I am not familiar with, such as attending Dr Freedman's course earlier this year to learn the needle's eye snare.
Dhoot: If you are collaborating with someone on lead extraction, it is important to “divvy up” the exposure. Meaning, one person goes to a symposium and gains that experience, the other person investigates a different technique, and then both operators discuss and incorporate some of these techniques. Having a partner allows for more opportunity to get the experience needed post training.

What is your “one big thing” or takeaway with respect to lead extraction? 
Lee: For me, it is about making the procedure as safe as possible. Consent is important for any procedure, but with lead extraction, there can potentially be some catastrophic complications. So, it is one of the few procedures where I even include the family as a part of the consent. I want everyone to be informed. There are some programs that only use laser, others that only use mechanical, or others that do superior versus inferior. To maximize safety, it is better to know all the techniques available, and from there, tailor the procedure to that patient. It is better to learn as much as you can, whether it is in fellowship or in practice through symposiums and training programs, and try to make it as safe as possible with a very clean solution to potentially change patients’ lives. Whereas some centers will recommend lifelong antibiotics, if you are able to extract the system, patients can do well. So, it is important to offer this program. With more implanters, we will be doing a great service to future patients.
Dhoot: With good support, sufficient volume, and the proper tools, lead extraction success rates are very good and it is a very safe procedure. It is not nearly as daunting as perhaps it is made out to be. Being involved in the program here has assured me of that. 

This content was published with support from Cook Medical.

The transcripts have been edited for clarity and length.