Preserving Diagnostic Electrophysiology Skills: Essential Competencies for Today's Electrophysiology Fellows

Preserving Diagnostic Electrophysiology Skills: Essential Competencies for Today's Electrophysiology Fellows

Kamran Namjouyan, DO

Heart Institute, Geisinger Medical Center, Danville, PA, USA, 17822

Electrophysiology is going through one of its most productive phases ever. Pulsed field ablation (PFA) has altered the way we deal with pulmonary vein isolation. The activation patterns which previously had to be assembled by hand over the whole of a study can now be shown in real time by high-density mapping systems. Conduction system pacing has moved from being just a new idea to becoming a mainstream option as an alternative to right ventricular pacing. For patients who cannot tolerate a transvenous system, leadless devices have broadened the range of services that a device clinic can provide. It really is an extraordinary time to be joining the field, and the fellows of today are likely to become the most technologically competent generation of electrophysiologists that the specialty has ever produced.

The expansion outlined in the 2026 ACC/AHA/HRS Advanced Training Statement on clinical cardiac electrophysiology is taken into account by incorporating conduction system pacing, leadless pacing, left atrial appendage occlusion, advanced imaging, and pericardial access into the main curriculum. Rather than using the number of procedures as a criterion for readiness, the statement deliberately moves away from this approach and asks programs instead to assess proficiency and outcomes by means of direct observation and committee review [1]. It must be remembered that a case log has always been an inadequate stand-in for true competence. The more difficult question which the statement does not entirely resolve is what becomes of the reasoning behind a procedure once that procedure itself has become easier to carry out.

Electrophysiology has always been a discipline of mechanism before technique. Long before a catheter reaches the heart the same three questions apply: what is the arrhythmia, what is driving it, and what does the available data actually prove? A high-density activation map only matters because of the physiology it represents. An entrainment maneuver is only useful because of what the response reveals about the circuit. Conduction system pacing is only meaningful because of the His-Purkinje anatomy it engages [2,3]. Technology is at its best when it sharpens that reasoning. It becomes a problem only when it starts to substitute for it.

A single-shot PFA case requires fewer independent technical decisions to achieve pulmonary vein isolation than a point-by-point radiofrequency lesion set did. An automated map appears in seconds rather than after twenty minutes of deliberate point acquisition. An algorithm flags a possible gap before the fellow has finished reading the electrogram [4]. None of this reflects fellows learning less. If anything, today's trainees are exposed to a wider range of procedures and earlier than any previous cohort. What has changed is how the underlying experience is built.

The repetition that used to force a trainee to work through a difficult tracing independently now happens less often, simply because the system gets there first.

This concern is consistent with a broader literature on automation bias and physician deskilling, which suggests that reliance on automated systems can erode performance when those systems are removed. A multicenter observational study of endoscopist "de-skilling" after regular exposure to AI-assisted colonoscopy and it is the clearest empirical demonstration, yet that automation can erode the very competence it was meant to augment. This pattern is not unique to electrophysiology. Across four centers, non-AI-assisted colonoscopy fell after operators had spent time working with computer-aided detection. A tool that reduces the interpretive burden per case can over time degrade the unaided reasoning it was supposed to sharpen [5,6]. Early-career clinicians may be particularly vulnerable, as they have had fewer opportunities to build and reinforce these skills through independent repetition. A recent comparison of fellow and attending operators performing pulmonary vein isolation found that attendings achieved shorter inter-lesion times and more stable catheter contact across every anatomic region studied, a difference the authors attribute to the accumulated procedural and anatomic reasoning that separates an experienced operator from a trainee [7]. Radiofrequency ablation still demands continuous catheter manipulation and real-time interpretation. This demand appears to be exactly what builds the reasoning. PFA by design does not demand it in the same way. Multicenter data place the operator learning curve for procedure and fluoroscopy time at roughly 18 to 20 cases [8,9].

None of this argues against the technology, and it should not be read that way. PFA, automated mapping, and conduction system pacing exist because they make patients safer and outcomes better. EP fellows should never be trained to distrust a tool simply because it works well. The point is narrower, and I think more useful that technology should extend the electrophysiologic reasoning and not quietly stand in for the repetition that used to build it. It is the one where the map does not add up; the tachycardia changes mechanism mid-study, an ablation lesion fails to terminate the arrhythmia despite an apparently correct target, or a device algorithm simply misclassifies an event. In that moment, the fellow has to return to first principles: interpret the electrograms, reconsider the differential, understand what the pacing maneuver actually showed, and decide what the data proves. That is not a nostalgic skill. It is the whole job.

The future of EP training is not a choice between the electrophysiologist who thinks and the electrophysiologist who is technologically fluent. It requires both, and there is no reason it cannot produce both. The fellows finishing training today have access to a set of tools no previous generation had, and they should use all of them without apology. What will distinguish the strongest among them a decade from now is whether they can still explain without a screen in front of them that why an arrhythmia is happening and what the data actually proves. Technology should make that reasoning sharper. Training should make sure it never gets the chance to make it optional.

Disclosures: None

Conflict of Interest: None

AI Disclosure: KN wrote and critically edited the article, including its ideas, analysis, and conclusions. An AI model was used for grammar and spelling edits (Clinical AI Score: 1 point). The total Clinical AI Score for this manuscript is 1 point.

References:

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