Academic Versus Private Practice: Which is Better for Electrophysiologists?

In this episode of The EP Edit podcast, Jodie Elrod (Managing Editor of EP Lab Digest) speaks with Sandeep A. Saha, MD, MS to get his perspectives as an early career electrophysiologist on the differences between academic and private practice electrophysiology (EP). He discusses some of the challenges that early career electrophysiologists face, provides helpful tips from his own experience, and shares the advice he received from colleagues and mentors. Dr. Saha is a cardiac electrophysiologist with Oregon Heart Center, PC, and Salem Health Hospitals and Clinics in Salem, Oregon. Of note, bonus content in our July 2019 issue includes his responses to our additional questions outside of this recorded podcast.

You can also listen to this episode on Spotify and Apple Podcasts!

Transcripts: 

Describe your medical background, including your role and work in EP today.

I finished my medical education at the Seth GS Medical College and King Edward VII Memorial Hospital at the University of Mumbai, which is consistently one of the top 10 medical colleges in India. After finishing my medical training, I did my internal medicine residency at the Chicago Medical School, and after completion of residency, I went to work as an academic hospitalist at the Providence Sacred Heart Medical Center in Spokane, Washington, and was clinical faculty at the University of Washington School of Medicine. I was in this role for five years before the fellowship bug hit me. I went back to fellowship training, starting with a one-year fellowship in echocardiography at the University of California in San Francisco, and then fellowships both in cardiology and cardiac electrophysiology at Rush University Medical Center in Chicago. During my time at Rush, I also earned a Master’s degree in clinical research from the Graduate College of Rush University. I now work as a cardiac electrophysiologist at the Oregon Heart Center, which is an eight-member private cardiology practice group in Salem, Oregon, and I am on staff at Salem Hospital. My clinical practice encompasses the entire clinical spectrum of clinical cardiac electrophysiology, which includes management of implantable cardiac devices, and cardiac ablations for both simple and complex atrial and ventricular arrhythmias.

I am also a member of the Communications Committee at the Heart Rhythm Society, and a member of the Cardiovascular Management Digital Communications Working Group, and Leadership Working Group at the American College of Cardiology.

Why did you choose a private practice setting?

It’s an interesting transition, because in my previous position as a hospitalist, I initially was employed by an educational consortium as one of the faculty members for the internal medicine residency. After about two and a half years, our hospitalist group was included into the multispecialty hospital-owned medical group, and the educational consortium essentially dissolved. So I saw the transition from being employed by an academic-oriented administration to a very cost-sensitive, hospital-owned medical group. Employed positions have a lot of advantages compared to being in private practice, but I felt that once I was in this employment role, I had limited opportunities for personal growth and also to make a meaningful impact in the way that we take care of our patients. Institutional bureaucracy and culture, at least in my opinion, can sometimes undermine the ability of certain clinical service lines to improve the processes and policies that can actually impact the patient care experience, clinical outcomes, and efficiency in a positive way. Sometimes, institutional priorities and a burning desire to sometimes curtail costs — literally at all costs — can also hamper the ability for bringing in state-of-the-art technologies and procedures that can benefit our patients, even if there is ample clinical evidence supporting their efficacy and value. I had limited impact in the way I was taking care of my patients in this employed setting, so I felt that it just wasn’t the correct environment for me — it was not an environment that I could thrive in.

When I finished my fellowship, I started looking predominantly at private practice opportunities, which in today’s landscape, are fewer and farther in between, as a lot of cardiology groups have either strategically aligned or merged with healthcare delivery systems. But I think being in private practice allows me to tailor my practice patterns to my clinical skills and interests, and it also helps me impact the healthcare landscape within my specialty in the community that I serve. I get to work with like-minded physicians who feel the same way and genuinely care for their patients. I also feel that I can have a larger impact on day-to-day operational decisions within the practice, and help in the overall evolution of cardiovascular care within the community that I serve. So for a lot of these reasons, I really feel glad to be in this private practice setting, to develop myself personally as well as have a larger impact on the overall cardiovascular care of my community.

What do you believe are some of the main challenges that early career EP physicians face?

Being an early career physician myself, I think we face a number of unique challenges — whether you are in private practice, in an employed setting in academia, or in a community hospital. Some challenges are inherent with transitioning to a job after completion of training. The fellow to independent practitioner transition comes with a lot of challenges, such as the apprehension of practicing independently and also developing a favorable reputation within the institution that you join. As in any other procedural specialty, there is a learning curve, and early career EPs take a variable length of time before they can feel comfortable with their skill levels within the EP lab. They have to adjust to working with a new lab, new systems, new staff, and sometimes the lab environment that they encounter in the workplace is very different from what they are used to during their training. EP procedures in general can sometimes be very long and technically challenging, and one of the beauties of EP, at least for me, is that it forces me to “think on my feet” while I’m doing these procedures, and respond to subtle changes that we see during the procedure. It can be exhausting, and sometimes you get caught — at least early on — in this fundamental conflict between being thorough and being efficient. Every operator eventually finds that balance between these two opposing forces, but I think in electrophysiology, especially procedural EP, this can take a little longer than some other specialties. Most of us EPs tend to be hard-driving type A personalities; we set the bar really high for ourselves, and we kind of get frustrated with ourselves early on as we’re trying to become efficient and thorough and get our cases done on time. We’re constantly trying to ensure, for the patients that we take care of, that we’re safely doing these procedures. Being in this situation for a little less than two years now, I honestly continue to struggle with this myself, although I think I am improving. But I think that is one of the major challenges that early career EP physicians face.

What specific skills would you say are crucial in EP early on?

Starting out, I focused on developing a consistent and systematic approach toward whichever procedure I was doing, however simple or complex it would be. During fellowship training, we work with a number of attending physicians, and all of them tend to have some procedural idiosyncrasies. We adapt to them during our fellowship years, but once we transition to practicing independently and doing these procedures on our own, one of the things that I focused on was to identify the idiosyncrasies that I wanted to incorporate into my own techniques, and which ones I wanted to modify or even eliminate. Early on, developing a systematic or consistent approach when doing procedures can provide a level of comfort, and procedural efficiency is bound to follow. Early career EPs should be patient with themselves — the process takes time. Once you’ve developed your own technique and methodology of doing things, whether it’s an ablation procedure or a complex device implant, you see yourself doing the same steps over and over again, and at a certain point you become more efficient.

The other crucial skill within procedural EP is to know your limitations early on, and realize that this is still an extension of the learning process being in the early career phase of practice. Do not hesitate to seek help from either your partners or other EPs in the hospital, and also seek advice and counsel from your mentors. I finished my training in Chicago and now practice in central Oregon — a couple of time zones apart — but I still call upon either my more experienced EP partner within the practice or my mentors from Chicago if I anticipate difficulties during the case. I talk with them and seek their advice, and it’s amazing how many practical tips and tricks that I have learned from my partner or my attendings that I did not have the opportunity of learning before during fellowship.

The other tool that I use, and increasingly so, is with the increasing power and scope of social media within the EP community, I can literally now consult with my mentors a couple of time zones away, as well as other experienced EPs from all over the world. I can ask questions and seek opinions from some of the most distinguished minds within our field — sometimes almost in real time. I think that is a powerful resource that we have literally in the palm of our hands, and if used appropriately, it helps the early career EP make great strides toward improving both knowledge base and procedural skill.

Do you participate in early career research as well? If so, what are some of the hurdles and opportunities when establishing a funded research career?

Being in private practice or even in a community-based practice, research tends to be a minority in terms of the work that you do, because clinical care of patients is the prime objective. For example, we have a limited clinical research enterprise within the hospital where I am on staff, and a small number of industry-sponsored clinical trials that we contribute to. But in terms of establishing a research career, especially funded research with grants from the NIH or other funding sources, the majority of that research is still well within the realm of academic medical centers or cardiovascular institutes within private healthcare systems. That said, I think for people who are in community-based private practice, there are opportunities within clinical EP to collaborate with industry and to get involved with, in some cases, some state-of-the-art clinical research trials testing new technologies or device components. Some of it is based on how much resource is available at the hospital or the healthcare system that you work at, and how much research plays a role within the institutional priority list. So my recommendation would be for people who are early in their careers and interested in research, to explore those possibilities within and find out if there are existing clinical research trials that their institution is participating in. Next, reach out to established researchers within your field of expertise or interest, and see if there is a way to develop a collaboration. Basic science research requires a much more committed percentage of your time — especially a funded research career, which really requires protected time — and there are various ways of doing it within academia. You can also be creative within the private practice realm and still have a chunk of time that you can devote to research.

What top tips can you provide for a successful early career in EP?

It’s important to develop and refine your own procedural skills, and again, early on having a thoughtful and systematic approach to doing procedures will help you avoid mistakes and compromise patient safety. Speed and efficiency will develop organically — as you get more and more efficient with your procedures, it is going to happen — but it’s important that early career EPs stick with the fundamentals and be patient until they reach that level. That is one of the messages that I would constantly get from my senior EP partner, and a lot of times, from my mentors back in fellowship — that things take time, to trust the process and be patient.

The second thing that I think is important for EPs is to be able to be in constant communication with your mentors and people who you look up to beyond the clinical training phase. I frequently interact with my mentors, ask them questions, and post questions on social media to help me with clinical decision-making. I think that has really increased my confidence, knowledge base, and comfort level in taking care of complex EP patients.

The next step that I would convey to early career EPs would be to develop a social media presence. If you don’t have a Twitter account of your own, it might not be a bad idea to get one, and follow the online EP community using hashtags such as #EPeeps, #CardioTwitter, and #earlycareerEP. Following top influencers within the EP community (on Twitter and other social media platforms), it’s amazing how much access this allows to the clinical experiences, insights, and opinions of some of the top minds in EP.

Having good communication skills also helps with team building. Especially in a new environment, being able to generate healthy communication with members of the EP team and nursing staff goes a long way in terms of developing that reputation within the institution of being approachable, and being teachable if necessary. A little patience and courtesy go a long way, especially when we’re in the middle of a complex procedure day and have a lot of clinical tasks that we’re trying to complete within a short period of time.

How have you utilized the Heart Rhythm Society in your early career?

The Heart Rhythm Society (HRS) has been a very crucial part of my development, and most early career EPs will recognize that as well. Amongst the different medical societies that I have been involved with in the past, HRS is very open to welcome and include fellows and early career EPs to join committees, get involved with activism and patient advocacy, and foster interdisciplinary collaborations both nationally and internationally. The HRS’s annual scientific sessions is a great conference to learn about state-of-the-art advancements in our field, and a great venue to expand one’s learning and networking base. It’s also a great forum to showcase your own research to the international EP community. Finally, in my role as a member of the HRS Communications Committee, I’m continuing to devote my time and skills to help with the mission of the Society to increase the level of engagement of the HRS with its membership, and I hope to continue in that role and contribute as much as I can.

Thank you so much for joining us! It was a pleasure speaking with you.

Thanks so much for having me. 

---

Bonus Content! Additional Q&A with Dr. Saha

What is important to keep in mind when pursuing clinical practice versus a basic science path?

The primary focus of clinical practice is the patient. One of the fundamental joys for me of being in clinical practice, especially in clinical EP, is the tangible impact that I can have on the patient’s life and well-being. Just the other day, I was at a restaurant when a patient of mine came up to me and told me how well he felt since I did an ablation procedure for him a few months ago, in spite of his initial reluctance to have it done when I first saw him in the office. He told me how it has allowed him to go back to fishing, sailing, hiking, and doing all the things he enjoyed before he got sick. To me, there is no more satisfying feeling to see that all the years of training and sacrifice have provided me with the tools to help people like him. It makes it all worth the effort, and I would do it all over again if I had the chance.

That said, our colleagues in basic science provide us with the insights and key breakthroughs that lead to the clinical advancements that we can bring to our patients. I hope I can acknowledge their invaluable contribution to the field by sharing success stories about patients, like the one above.

What specific tips have you also received from colleagues and mentors?

A useful tip I received from one of my partners is to reach out to your referring providers as much as possible. With the capabilities of our EHRs, many of the letters and notifications between practices are automated; however, there is tremendous value in picking up the phone and having a direct conversation with your colleague about your mutual patient — it allows you to address any questions they may have about the plan or procedure, develop a personal connection, and directly contribute to timely and effective patient care. I also often use the messaging feature of our EHR for this purpose.

How do you maintain work-life balance?

Having work-life balance is difficult, especially as an early career EP in a relatively small private practice. On non-call office days, I try to take my son to/from school and after-school activities as much as possible. I try to have dinner with my family every night, even if it is a call night. I also practice yoga, and learn and practice meditation.

Is there anything else you’d like to add?

It’s important to acknowledge the support and sacrifices of your loved ones as you transition from fellow to independent EP practitioner. For many of us, the road to being an EP physician has been a long and arduous one, and although we have spent what seems like a lifetime studying, taking call, doing procedures, conducting research, writing papers, etc., there are people in our lives who have also shared in the trials and tribulations. I know how much my wife and my son have contributed to enabling and inspiring me to stay focused and on track.

Lastly, being an early career EP physician can be an adventure, but you are not alone on this journey. You have worked hard to reach this stage, and your patients count on you to be the best EP you can be. You have what it takes, and you would not be here if you didn’t. I wish you every success.