Cardiac Rhythm Management
Articles Articles 2011 September

Expert Commentary: Entrance without Exit Block during Pulmonary Vein Isolation

Ralph J. Verdino, MD

University of Pennsylvania School of Medicine

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E-mail: Ralph.Verdino@uphs.upenn.edu
Associate Professor of Medicine, Program Director, Electrophysiology Fellowship
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

 

Ralph J. Verdino,

It seems that working in an academic medical center gets a little harder every day. The age-old pressures to publish papers, secure grant funding, and receive excellent teaching evaluations still remain, but the benchmark to determine your worth to the institution seems more and more related to revenue. Faculty meetings are increasingly focused on RVUs targets, strategies to increase procedural volumes, and ways to improve outpatient clinic efficiency in order to see more patients. Kaplan–Meier curves showing differences in survival outcomes between treatment and placebo arms have given way to bar graphs comparing yearly numbers of ablations performed at the institution. The electronic medical record has stolen “face time” between patients and physicians in order to allow computer time for checking boxes. The few thousand dollars you received for the hours you spent creating lectures for an industry-sponsored fellows' program, the hours of travel time it took to reach your destinations (usually in cities like Minneapolis and Austin and not Honolulu or Vail), and the days away from your family and friends must be disclosed on national and university websites as if you were receiving a campaign contribution or convicted in a money laundering scheme. There are increasing regulations restricting work hours for house staff, resulting in greater numbers of “hand-offs” that result in more middle of the night pages to attending physicians to clarify treatment plans.

 

In spite of all these challenges, faculty positions in cardiac electrophysiology at academic medical centers are harder and harder to find. Many possible theories for this phenomenon may be invoked, from an overall downturn in the economy and a high national unemployment rate, to uncertainty related to Obama's health-care legislation, to a concern that fellowship programs are turning out too many electrophysiologists. I suspect some of these observations may have merit, but I believe the article entitled, “Entrance without exit block during pulmonary vein isolation,” by Drs. Frankel and Riley, may hold some clues as to why academic electrophysiology jobs are so scarce. I believe that within the article lies the reason I continue to come to work every day despite all of those annoyances I mentioned in the first paragraph above. It has nothing to do with catheter ablation, and it is not related to atrial fibrillation. In fact, it has not is nothing to do with cardiac arrhythmias at all.

The feeling I get seeing names in print of fellows that I help train over the years makes it all seem worthwhile for me in spite of the challenges encountered in my academic medical center. I remember teaching the basics of electrocardiography to Dr. Frankel while he was a medical student and recall discussing the differential diagnosis of a patient's condition with Dr. Riley during his internal medicine residency. I watched as both of these very bright physicians rotated through the disciplines of general cardiology fellowship and was there to help ignite the fire when sparks of interest in the field of electrophysiology were not where realized by both budding cardiologists. I was fortunate to participate in teaching them techniques of device implantation and general approaches to caring for patients with cardiac arrhythmias. I was honored to be there for them after their patient experienced a procedural complication, to add a little support and to help them learn from the experience in order to best care for this patient and the many other patients they would care for in the future. I was privileged to get a knock at my door after their first clinic day as an attending to hear about a couple of their challenging patients, not to come up with the diagnosis or treatment plan, but just to reassure them that their diagnosis was a good one and their treatment plan sound. Those knocks came over 4 years ago from Dr. Riley's hand and only a few weeks ago from Dr. Frankel's.

I believe that being intimately involved in training the future generations of great electrophysiologists is the best part of academic electrophysiology, and it makes all of those annoyances in paragraph one seem trivial. I suspect that the feeling I get seeing my former fellows succeed both academically and clinically is shared by so many academic cardiologists and is one of the reasons why the “Help Wanted” signs are so rare these days in academic medical centers.

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