The Beginnings of an Electrophysiology Training Program at the Medical College of Georgia

Robert A. Sorrentino, MD, FHRS, FACC Creel Professor of Medicine Interim Chief, Section of Cardiology Director of Arrhythmia Services Program Director – Clinical Cardiac Electrophysiology Medical College of Georgia Augusta, Georgia
Robert A. Sorrentino, MD, FHRS, FACC Creel Professor of Medicine Interim Chief, Section of Cardiology Director of Arrhythmia Services Program Director – Clinical Cardiac Electrophysiology Medical College of Georgia Augusta, Georgia
This article is not intended as a recipe for programmatic development. It is my personal experience in starting an EP program. I was given the unique opportunity to both start an EP clinical program and develop a fellowship training program. Included is an inside look at how our EP training program was started. Background In the fall of 2003, I was asked by the Chief of Medicine at the Medical College of Georgia (MCG) to contemplate building a cardiac electrophysiology (EP) program at the Medical College in Augusta, Georgia. When he asked, I was the Clinical Director of the EP program at Duke University Medical Center. Duke was where I had done all of my post graduate training, including Internal Medicine, Cardiovascular Diseases and Clinical Cardiac Electrophysiology. Duke has a long tradition in EP, and its training program has produced many distinguished academic and clinical electrophysiologists, some of who are also leaders in the Cardiology and EP communities. The current trainees and EP faculty at Duke continue to reap the benefits of being part of such an EP pedigree. At the time of my recruitment visit, the MCG Section of Cardiology was in the midst of change. I was impressed with the institution’s commitment to grow their cardiovascular services. However, the division was without a chief at that time. I was going to need someone higher up the administrative ladder to also be a champion of the EP program. My tour of the facilities was eye opening. The old EP lab was a real swing lab, that is, an elongated room with a C-arm fluoro centered between two fluoroscopy tables, one on each end of the room. One side of the room was designated the cardiac catheterization lab and the other half of the room was the EP lab. Each lab had their respective unique recording or therapeutic equipment. Unfortunately, this type of setup only allowed one lab to be used at a time. An additional concern was that the fluoro equipment was old and it was getting increasingly difficult to find replacement parts when they were needed. There was also no residing EP consultant at the time. Part-time faculty performed a limited number of simple EP cases: pacers, ICDs and infrequent ablations. There was a dedicated EP nurse who assisted in the EP procedures and knew the rudiments of pacer and ICD follow-up. Overall, I was looking at under-developed EP services and antiquated equipment. MCG was proceeding forward with my recruitment while also recruiting a new cardiology section chief. There was something attractive about being given an opportunity to build a program from the ground up. At the end of my recruitment visit, I left the Chair of Medicine a long wish list of critically needed items to build an EP program, which included a dedicated state-of-the-art EP lab, EP staff and provisions to create an EP fellowship training program. The cost of building an EP program was going to be $3-5 million. I didn’t think I’d be hearing back from MCG anytime soon. About six months later I was approached by the recently recruited Cardiology Chief, Guy Reed, MD, PhD, who had come to MCG from Massachusetts General Hospital. Dr. Reed had an excellent understanding of clinical EP, having considered EP as a career choice before committing to coagulation and thrombosis research. This new prospect came when I was beginning to have uncertainties about my career path at Duke. I came back to MCG to meet with the new Division Chief, Dr. Reed, the Dean, Medicine Chair, hospital CEO and other administrators. At the completion of my second visit, I left Dr. Reed an updated and even longer shopping list of needs to build a clinical EP and training program. MCG made me an offer to make an EP program happen at MCG and I accepted the job in the fall of 2004. Getting Started Starting an EP program with an already present infrastructure, faculty and clinical base is probably an easier feat to accomplish. I was going to start from zero. Building a program from scratch has its advantages, because what you create is of your own design and there is no inherited baggage. However, a huge drawback in starting from the ground up was the need to build an EP clinical practice where there was little to none. Multi-tasking was going to be routine in starting an EP program, including the planning and development of the clinical practice, staff, facilities and the fellowship training program itself. To get started, the first thing I did was go to the American Board of Internal Medicine’s (ABIM) website1 for the most current requirements for Clinical Cardiac Electrophysiology (CCEP) training and board certification. If we were to have an accredited EP training program, we had to ensure that our trainees would qualify for taking the ABIM board certification examination in CCEP. A challenge was to project reasonable and attainable EP case volumes that would at least meet the minimal case load to support a single EP trainee. MCG had done few EP cases in the two years before my arrival, so I was going to have to build a case volume. The ABIM requires fellows to perform a minimum of 150 intracardiac procedures in at least 75 patients, of which 75 are catheter ablations and 25 are initial cardioverter-defibrillator implantations (including programming) in a one-year accredited training program to be eligible. The fellow must demonstrate proficiency in these procedures and be competent to provide comprehensive and specialized medical care in clinical cardiac electrophysiology, as determined by the training program director.1 The ABIM additionally requires documentation that candidates for certification are competent in the six core measures: 1) patient care, which includes medical interviewing, physical examination and procedural skills; 2) medical knowledge; 3) practice-based learning and improvement; 4) interpersonal and communication skills; 5) professionalism; and 6) systems-based practice. Anyone involved with any residency or fellowship training program will know the importance of competency in these core measures, and the successful completion of each is a major consideration given by the Accreditation Council for Graduate Medical Education (ACGME) when they perform sites visits and review training programs. Most currently active training programs easily exceed the annual case volumes listed in the ABIM requirements, but an informal discussion with EP program directors will confirm that the ABIM minimum number of cases in a one-year training program, although adequate to become board eligible, is not adequate to prepare a trainee for complex procedures like biventricular ICD implantation and follow-up, ischemic VT ablations, lead extraction or ablations that cure atrial fibrillation. Many EP training programs are offering a second year for advanced EP training in these more complex areas. I felt that since we were going to build a full-service EP program, we would need to plan on offering both basic and advanced EP training in order for us to become a competitive EP training program. We planned to have one new trainee per year, and would offer a two-year training program. The first year we would only have one trainee; for the second year and thereafter we would have two trainees, both a junior and senior EP fellow. The senior fellow would have the basic EP skills needed to allow him or her to learn the more advanced and complex skills in year two. Having the appropriate case volume and deciding on the number of trainees was only the beginning. Fellowship training needs financial support: salaries, benefits, and space for the trainee. We would also need a program coordinator to manage the fellowship and create and maintain the necessary documentation that is a critical part of formal accreditation for any training program. These provisions to support the EP program had been negotiated with my recruitment. The only way we could offer our trainees eligibility for board certification in EP was to become accredited by the Accreditation Council for Graduate Medical Education. The ACGME is a private, non-profit council that evaluates and accredits medical residency and fellowship training programs in the United States. A visit to the ACGME website, www.acgme.org, brings one to the repository of rules and regulations for all post-MD training programs. There are requirements and guidelines that are common to all programs, like the 80-hour work week. There are also listings of the rules that are specific to a particular sub-specialty. A review of the ACGME website made it clear to me that successful accreditation and maintenance of accreditation was going to make us become very familiar with all of the details prescribed by ACGME policies and procedures, and we would have to maintain precise and timely documentation of everything that pertained to the training program. I sought the help of the MCG office of Graduate Medical Education (GME), which was the internal body with the responsibility of overseeing all residency and fellowship training programs at the Medical College. The Associate Dean of GME is Walter Moore, MD, who has been instrumental and successful in the oversight and maintenance of residency and fellowship training programs across the whole institution. He and the GME office staff worked closely with the program directors and coordinators for each specialty and subspecialty at MCG. Dr. Moore was quite familiar with ACGME and how to successfully negotiate through all the policies, forms, applications and questionnaires that we were going to have to submit to the ACGME for the application, accreditation and re-accreditation process over the years in the life of a training program. He would also be the person supervising internal GME training program reviews in anticipation of the formal ACGME site visits that occur to maintain accreditation. A new program can expect its first review in one year and, depending on the degree of success of that review, may enter into a cycle of ACGME reviews every 3-5 years. The EP Clinical Program The EP clinical program was really beginning to take shape. A new state-of-the-art biplane fluoro EP lab was constructed, and we were finally able to abandon the swing cath lab. I hired EP lab staff and a nurse clinician. Our EP case volumes grew rapidly, and in less than a year, working as a solo EP at an academic institution, I was getting to my saturation point. I quickly needed to look for a second EP faculty, and more specifically, find someone with the skills of performing the complex ablations that would complement our programmatic development. I recruited Adam Berman, MD, who was completing his EP training at Duke, my former program. The addition of Dr. Berman to our EP faculty, as the Director of Cardiac Arrhythmia Ablation Services, gave us one of the last pieces of the ACGME requirement needing to have two faculty who are ABIM board certified in Clinical Cardiac Electrophysiology. Dr. Berman’s arrival further grew our case volume and case mix well beyond the minimal requirements for the ACGME. Shortly after his arrival at MCG, he and I began working on the Program Information Form (PIF), which is a key part of the application process to the ACGME. The PIF lists all the requirements and ensures that the applying program meets all of the ACGME standards. The Fellowship Training Program The addition of Dr. Berman as EP faculty gave us time to teach and stimulate the interest in EP to our cardiovascular fellows, most of whom had never considered EP as a career choice before. We were very pleased to learn that three of our fellows wanted to pursue EP. Unfortunately, the ACGME application process didn’t proceed quickly enough for us to be able to offer one of our own internal candidates for MCG’s first EP training position. We were successful, though, in helping all three fellows apply and gain admission into already established and accredited EP training programs. Our turn for fellow selection had to await program approval by the ACGME. In July of 2008, MCG and two other programs became newly accredited in EP. During the application process we recruited a program coordinator who was going to be a key person for maintaining the flow of paper and electronic documents between the MCG GME office and to the ACGME. The program coordinator needed to have the qualities of independence, persistence and organization. The program coordinator had to be meticulous in record keeping. This person needed to have a degree of obsessive-compulsiveness yet possess some qualities of a den mother at times. It is the role of the coordinator to help ensure that the program, faculty and trainee are compliant with institutional GME and ACGME standards. We were fortunate to find these qualities in Betty Carrera, who became our EP Program Coordinator and EP Section administrative assistant. Once hired, Ms. Carrera quickly began becoming very familiar with the ACGME website. We arranged for Ms. Carrera to attend program coordinator training courses that were offered through the MCG GME office and through the ACGME itself. The last and biggest hurdle was finding a suitable fellow. The timing of the accreditation notification backdated to July 2008, but we didn’t actually receive this notification until later in the year. Unfortunately, our last potential internal EP candidate had already committed to another institution when we received our letter of accreditation. One might think that there are EP fellow applicants in abundance, but trying to get the right fellow for a newly accredited program was going to be a challenge. The MCG EP training program was unknown and untested. Most fellows are looking to get into well-established programs, hopefully one with a known reputation for EP training excellence. We didn’t have this to offer yet. One should note that EP training programs are not subject to the National Residency Matching Program (NRMP) as are cardiovascular disease programs. Not having to go through the NRMP greatly simplified our recruitment process, and we could create our own timeline for the application process. We advertised the position in several EP journals and websites. We also pursued a grassroots EP fellow search by word of mouth to our EP friends, colleagues and EP catheter and device industry representatives. We received many CVs of prospective candidates, some of whom came with their own funding source to pay for their training. The vast majority of candidates failed to meet one major application requirement, which was to qualify to take the ABIM certifying exam in CCEP. Many of the candidates were from overseas or foreign nationals training or working temporarily in the U.S. who were not board eligible. An important criterion for maintaining accreditation is that the trainee successfully passes the ABIM CCEP exam. We had to find a candidate who would complete this ACGME requirement. The late timing of receiving our accreditation put us in a difficult time of year to recruit, since most of the best candidates had already committed to well-established programs. We persisted in our search and had the opportunity to evaluate several candidates that would fit our new program. We selected Prabal Guha, MD, who had trained in Cardiovascular Diseases at SUNY Syracuse and then worked in South Carolina as a general cardiologist for several years paying back his public service debt. Our fortune was that Dr. Guha had a long interest in EP and had even done some basic EP research at SUNY Syracuse. His time in practice had given him the maturity and experience that made him the best suited of our candidates. He was selected to be our first EP trainee. Our expectations of Dr. Guha are high, but I am confident he will exceed them all. Update In September of 2010 we will have our first ACGME site visit, and their analysis will determine our ability to maintain this training program. In anticipation of that visit, we recently had the first internal review of our program by the MCG GME committee. I had participated in many similar reviews for cardiovascular disease and EP programs before, but this was my first as a program director. The weeks preceding our internal review were full of forms, documents and spread sheets that needed review and updating. Ms. Carrera, our program coordinator, has only worked in academic medicine for about 7 months; she had never been part of such an audit. We were all very nervous and were paying even more attention to detail than our usual state of attentiveness. Fortunately, the internal review of our program went very well. I am very optimistic about the future growth and success of the MCG CCEP training program. We will be very well prepared for our ACGME visit scheduled for September of 2010. Our EP program continues to grow such that we are in the process of building a second EP lab and recruiting additional EP faculty and staff. We are also looking to recruit our second EP fellow to start in July of 2010. Acknowledgements I want to thank the Medical College of Georgia - School of Medicine and Hospital for all their support in the creation of an EP service and the CCEP fellowship training program at the Medical College. I acknowledge my EP partner, Adam Berman, MD, whose hard work and advice has been indispensable toward this endeavor. I thank Dr. Moore and his staff at the MCG GME office who have kept us on track and provided us with the wisdom and encouragement to work through the complex rules and regulations that accompany the upkeep of a training program. I am grateful to Betty Carrera, our program coordinator, overseer, and task master whose personality and perseverance has perfectly fit the role as a program coordinator. There is a long list of others who have had some impact on the formation of this EP training program, and I am grateful for all their support. Lastly, I am thankful for the support of Dr. Guha, our first EP fellow, who has been very hardworking, studious, pleasant to work with, and patient. Patience is always an important virtue to any trainee, but it is particularly important when one is in a new training program, as there are new things being learned by all those involved. The ability to train a fellow is a privilege, and we feel truly privileged having him in our program. His input is highly valued and will help us improve the training experience, which will also impact future trainees. As of July 2009, the Medical College of Georgia Clinical Cardiac Electrophysiology training program is one of 97 CCEP programs training about 180 fellows across the U.S. For more information, please visit: www.mcg.edu/som/medicine/Cardiology/ep_fellowship/index.html