Training in Cardiac Electrophysiology: The Lahey Clinic Experience

David Martin, MD
David Martin, MD
The practice consists of approximately 1,000 physicians in multiple sites; the Cardiology Department has twenty-five staff physicians with three full-time electrophysiologists. Training in this institution is performed at multiple levels, and there exists active relationships with both Harvard and Tufts Medical Schools for the teaching of medical students. In addition, there are medical and surgical residency programs as well as residencies in multiple medical and surgical specialties. Cardiology training is one of the many subspecialty programs that are offered within the Department of Medicine, and within the Department of Cardiology, there is subspecialty training in interventional cardiology and cardiac electrophysiology. The cardiac arrhythmia service at Lahey Clinic is staffed by three full-time faculty with plans to add a fourth in July 2003; two electrophysiology laboratories will be functional by the spring of 2003, and there will be two physician assistants dedicated to the arrhythmia service in addition to two device/clinic nurses and one research coordinator. The Lahey Clinic Cardiac Electrophysiology Fellowship Program has been in existence since 1989 and has been training one or two fellows annually during this period. There is currently one accredited position, and within the next few months, it is expected that this will be increased to two positions, both of which have full salary support from the institution. The Fellowship Program. Cardiac electrophysiology fellows must be board-certified in Internal Medicine and board eligible in Cardiology at the time of their appointment. It is expected that training in cardiac electrophysiology be completed within one year; therefore, it is expected that the trainees be sufficiently experienced to maximize the educational benefit of the training program from the moment the academic year begins on July 1. We offer an intensive clinical training in which fellows are typically exposed to more than 1,000 procedures in the course of the year. The cardiac electrophysiology fellow who graduated in 2002 had personally been involved in 1,500 laboratory procedures during the course of the year. The repertoire of procedures offered in the cardiac electrophysiology laboratory encompasses the full range of arrhythmia and heart failure therapies. Diagnostic electrophysiologic studies are performed frequently, with many hundreds being done during the course of the year. Approximately 300 catheter ablations are performed with the typical distribution between supraventricular tachycardias, atrial flutters, ventricular tachycardias and atrial fibrillation. Trainees in cardiac electrophysiology are exposed to the usual range of interventional techniques regarding catheter ablation with the use of trans-septal and other procedures, including intracardiac ultrasound. In common with many laboratories, we have recently increased the number of pulmonary vein mapping and ablation procedures that we are performing, and it is expected that the cardiac electrophysiology fellow will have an adequate exposure to these procedures during the course of a one-year fellowship. Device implantation is also a core activity in our laboratory. We expect to implant approximately 300 pacemakers and approximately 300 defibrillators during the course of the year. Of these devices, between 50 and 80 will be biventricular or cardiac resynchronization devices. Furthermore, the cardiac electrophysiology fellow is exposed tilt table testing and other non-invasive diagnostic procedures including testing for T-wave alternans. Fellows in cardiac electrophysiology spend the bulk of their time in the cardiac electrophysiology laboratory performing invasive procedures, and it is explicitly clear that the electrophysiology fellow will be the primary operator for all procedures when he or she is present in the laboratory. However, it is important that fellows also attend the follow-up clinics where pacemakers and defibrillators are evaluated in detail. There are a wide range of opportunities for fellows to develop familiarity with all implanted devices, both under supervision and semi-independently. Fellows also have a weekly continuity clinic with half session of consultation time in the outpatient setting. Patients are seen by the fellow independently and then discussed and evaluated jointly with one of the attending electrophysiologists who are present in the clinic. There are a wide range of educational opportunities available for the electrophysiology fellows, which include the presentation of cases at the monthly electrophysiology conference for the Department of Cardiology. In addition, the fellows are involved in the teaching of ECG interpretation to medical students and also participate in the lunchtime lecture series for the medical residents. Furthermore, the electrophysiology fellows coordinate the case presentations at the electrophysiology conference held on a weekly basis. It is important to emphasize that training in cardiac electrophysiology is an intensive experience, because there is a wide range of material to be learned in a short period of time. The ACGME required period of training is only one year, and although many institutions require a two-period training of their fellows, it has been the policy of our institution to require no more than what is required by the accreditation authorities. This is because training in medicine and its subspecialties is already very long and many trainees are anxious to get into practice since many are heavily in debt. Therefore, we expect during this intensive one-year training that fellows will gain practical experience from daily interaction with patients in the laboratory and other clinical settings. Their technical skills will grow rapidly, provided they are well grounded when they begin their fellowship; preliminary experience in electrophysiology for as many months as possible during the third year of cardiology training certainly helps this process. At the end of the training period, it is expected that graduates will be competent arrhythmia specialists in the consultative role and will be technically able to perform diagnostic and interventional procedures that are most frequently observed. In addition, all of our graduates will be capable of device implantation and revision. It is likely that experience with complex ablation will require a future period of experience which will most likely be gained in a practice setting. It is not reasonable to expect that a new graduate from a one-year electrophysiology program be seasoned in all of the different forms of ablation that are observed in clinical practice from time to time, since some of the more rare entities may be observed only once in a few years. Nevertheless, it is to be expected that all graduates will have the necessary grounding in terms of knowledge and experience to be able to tackle even the rare and complex problems with a systematic and rational approach that will be safe and effective. Recent changes in accreditation requirements regarding duty hours have had no effect upon the Lahey Clinic program, since the on-call responsibilities have always been deliberately minimized to ensure a high quality educational experience; there is no weeknight call, and fellows share call for weekends equally with the three (soon to be four) faculty members. However, the program (in common with all training programs in the U.S.) has been dramatically affected by the new competency definitions and the need for programs to evolve their curricula to reflect the proper evaluation of the defined competencies. Details of the general requirements regarding the core competencies can be accessed at the ACGME website (www.acgme.org); it is important to emphasize that definitions of competency (and, hence, development of tools for the evaluation of competency) are highly problematic for procedural specialties such as cardiac electrophysiology. However, it is likely in the next few years that new tools of evaluation, possibly utilizing simulators, will be developed, and fellows will be exposed to a wide range of testing prior to graduation from training programs. Similarly, it is likely that evaluations in the future will be performed not just by the training faculty, but also by the support staff such as nurses, secretaries and medical assistants. Furthermore, direct feedback from patients is also likely to be incorporated into the evaluation of fellows in all specialties, including cardiac electrophysiology. At Lahey Clinic, a task force of program directors from multiple specialties is currently working on these important issues in order that we can assure the public that our graduates are not just trained, but truly competent to do the work expected of them in practice. Benefits. Despite the foregoing, we should not forget that electrophysiology fellowship training exists to provide an educational experience that is rich and varied for its trainees. Electrophysiology fellows are not a form of cheap labor, and electrophysiology programs which maintain active fellowships should not require the presence of a fellow in order for the clinical service to function efficiently. At Lahey Clinic, we have two physicians assistants in addition to two dedicated clinic nurses, a research nurse and a host of laboratory staff which ensures that the cardiac electrophysiology fellow is protected from routine and mundane activities that are not directly related to his or her educational experience. Finally, training in cardiac electrophysiology is a highly rewarding experience for both the trainee and the facility. We are privileged to work in rapidly evolving field of medicine, and it is important for those practicing cardiac electrophysiology to be challenged by their trainees. It is the demands of training, formal teaching, and mentoring the new members of our exciting profession that keep us energized.