Should I Practice General Cardiology?

“EP Rising” is written by Dr. Ishu V. Rao, Director of Electrophysiology Services at Community Memorial Hospital (CMH) in Ventura, CA. Almost a decade ago, as I began my career in private practice EP, my mentor, Dr. David Cannom, offered this sage advice: “Resist the urge to practice General Cardiology.” As all good advice does, his spoke to me as an individual, reflecting my personality, ambitions, and skills. He knew then that I hoped to have a robust, diversified practice that covered all aspects of Electrophysiology, and he felt that I had the necessary skills and drive to achieve that. The reason Dr. Cannom advised me not to fill my free time with General Cardiology was simple: it is easier to find those patients and thus build a practice relatively rapidly. But patients like to stay with their physicians, and once a stable practice fills with heart failure, atherosclerosis, and hypertension patients, there is not much room left for the EP patients that were your initial target population. Also, the incentive to try to build an EP practice is much greater when you are sitting on your hands rather than seeing patients, performing procedures, and generating revenue. As I endured many quiet hours in the initial days and weeks of my first practice, I sought to find tasks to occupy myself. Practice building became my hobby, and downtime came to represent an opportunity. I collected cases, cines, echocardiograms, and ECGs, and methodically created a library of my own cases to show my peers and referring physicians. I cold-called primary care offices to meet physicians and educate them about my practice. I hosted roundtable dinner discussions with referring doctors, and gave lectures to physicians and patients. These efforts took time that I would have spent seeing General Cardiology patients had I elected to travel that route. Instead, I built an EP-only practice. Almost a decade later, my hobby is still practice building. I continue to collect cases and assemble talks that have yet to be scheduled, ever prepared to lecture. Last month, I gave evening talks or met with potential referring doctors or marketing partners at least twice a week. I find that if I go several weeks without engaging in these activities, my practice suffers. (It’s a bit like ball movement in basketball: good things come with more activity.) The habit is habit forming. The decision not to practice General Cardiology was the right one for me. But is it the right decision for everyone? The answer lies in the individual. Honest introspection is mandatory before deciding which type of practice one will develop. For people like me, practicing EP was a priority, and I was willing to forego rapidly building a practice with General Cardiology patients in favor of slowly developing an EP-only practice. Others might want to retain the General Cardiology skills that they worked so diligently to learn during their fellowship, and enjoy the diversity of a combined EP and General Cardiology practice. Not to be ignored is the effect of the marketplace on which type of practice is feasible. As more EPs filter into the community from fellowship training programs, bigger groups that can reliably feed an EP with only arrhythmia cases may no longer be hiring. However, smaller (2-5 person) groups may want to offer EP services but do not have the case volume to keep an EP busy full time with rhythm management. In those instances, practicing General Cardiology is a necessity to round out the EP’s practice. In my view, EP practices will begin to mirror Interventional Cardiology practices in that those practitioners will be expert in their technical fields, but also will spend a considerable proportion of their time practicing General Cardiology. The broader the EP’s skillset, the less dependent on General Cardiology they will likely find themselves. Almost all electrophysiologists trained in the current era gain experience in atrial fibrillation ablation, and many are training in lead extraction as well. Those that limit their practice to “bread and butter” EP — device implantation and non-AF/ non-VT ablation — will find that their ability to fill a lab may be seriously compromised. In my practice, I estimate that 40 percent of my ablations are AF. My lead extraction program, while not all consuming, is steady, and combined with PM/ICD/CRT implants and atrial flutters and (increasingly fewer) SVTs that come through the lab, my days stay full. Each of us must ask ourselves key questions when attempting to craft a practice. Chief among them is this: What do I want? In answering that question, while considering Private vs. Academic, Rural vs. Urban, and all of the other variables, do not ignore the prospect of incorporating some degree of General Cardiology and recognize the cold, hard facts. Can you survive in your market practicing just EP? Will practicing General Cardiology threaten other cardiologists who will fear losing their patients to you and consequently not refer EP cases? Conversely, will adding General Cardiology to your practice make you a more attractive addition to smaller Cardiology groups interested in providing an Electrophysiology service line? The people whose practices we admire likely did not fall into them simply by blind luck. A vision to guide the development of the practice to a goal is necessary. In my experience, that goal has changed as I myself have changed. Identify your skills and your goals, be realistic about the practice landscape, and craft a business plan. A business plan with short- and long-term objectives will provide an empowering road map to success. Dr. Ishu V. Rao is the Director of Electrophysiology Services at Community Memorial Hospital (CMH) in Ventura, CA, where he is leading the development of an expanded EP program as part of the hospital’s $350 million building project. For more information about Dr. Rao, please visit https://answersinaheartbeat.com/ To see another blog by Dr. Rao, please visit: https://eplabdigest.com/blog/Lessons-Learned-World%E2%80%99s-Largest-Democracy