Looking back


Milestones are to stop and look back on the road travelled. As the year ends, I am approaching the completion of seven years as an independent consultant electrophysiologist. I also recently completed 1000 device implants and 1000 electrophysiology procedures.

Uppermost is a feeling of satisfaction with how things have shaped up. These years have been a vindication of my decision to join and work at JIPMER. But there are other, more important things that I think summarise this period and what I have learnt from it.

Documenting the journey - Importance of maintaining records

From the beginning I have made all attempts to document all details of the interventional procedures and the follow ups. While this was cumbersome at times (not satisfied with what is available, I wrote the software myself, iterating through multiple versions over time), the benefits are undeniable. Having accurate data enables you to look back at your work objectively and quantitatively. It allows you to measure outcomes and compare them to established standards, which gives lot of confidence when judging the quality of your work. In any field, measuring your past performances gives you a feedback loop to help improve in the future.

Key performance indicators are are now well recognized as measurable indices of quality of work. Acute ablation success rates are easy to measure objectively and well reported from different centers. Since AV nodal reentrant tachycardia (AVNRT) is the commonest arrhythmia requiring ablation, success rates for this procedure are reliably measured and can be compared with available information. For device implants, cephalic vein access rates has been mentioned as a marker of quality of an implanting center. This is again an easy to measure metric though skewed a little for us because there is a learning curve with a low successful access rate for each trainee during the initial period. Atrioventricular block and infections are the most dreaded complications associated with ablation procedures and device implants respectively and our numbers are well below reported rates. With the data behind me, I can say with confidence that our work in absolutely on par with the best in the world.

Don't underestimate the learning curve

What the data also shows clearly, and which has been surprising for me, is the learning curve and how long it can be. Many measures, especially related to electrophysiology procedures, when plotted on a year-to-year basis, show a gradual and continuing improvement. This is evident for overall ablation success as seen above or success with specific procedures as seen below. At the end of 7 years and 1000 cases (closer to 1500 if all procedures I have participated in, instead of only those in JIPMER, are counted), I think they are reaching the point where they should plateau or at least grow little. Of course, one can't over-interpret, given that this is data from just one person, but I think it shows that these procedures involve skills which take time to learn and establishes the importance of working in a place with a large volume, especially in the formative years.

Publishing ... isn't only for the credits

Publishing is usually seen as a necessary evil, something that is required for your next promotion, but is otherwise a drain on resources and a waste of time that can be spent doing clinical work. On the other hand, I see publishing as another way to establish the authenticity of the work you do, an acknowledgement that the quality of what you do is acceptable at an international level. Publishing from here is a little more difficult than it would have been from a reputed center abroad, especially for research articles. Support while preparing the paper is less, and there is a definite, perhaps unconscious bias from reviewers / editors when the paper comes from an institute in India. With shorter reports, the bias has been less or non-existent however. I am especially proud of the teaching rounds kind of reports that we have published in all the major EP journals.

Learning to teach

Which brings me to one of the bits I have enjoyed the most in these years - teaching others. I have seen close to 20 cardiologists complete their training with us in these years and go on to work all across India. Teaching keeps you on your toes and, without doubt, is one of the best ways to learn. Teaching procedural skills without compromising patient safety of procedural efficiency while also allowing enough independence to build confidence to work independently requires the most exquisite balance. And looking at our results, I think we have maintained this balance.

But then finally it is about the patients

When we were training in medicine, our teacher used to tell the patients "Today you are helping us teach these students, in return they will help patients like you tomorrow." JIPMER is an unique institute where most patients are still provided free treatment which helps the most disadvantaged sections. So each day I feel the satisfaction of repaying some of the old debts. Working here in this position, making a difference to the lives of people is immensely more satisfying than being the nth electrophysiologist in a hospital abroad.