'Crucible of Crisis': Cardiology Fellows Adapt During COVID-19

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APRIL 22, 2020 -- Cardiology fellows-in-training, launching their careers just as the pandemic transforms cardiovascular units into COVID-19 wards, report on the challenges, unexpected opportunities, and a few lessons on how training programs could be better prepared for the next pandemic, in a series of new publications.

"I think the pandemic has inspired a great deal of innovation and creativity in medical education thus far," Nosheen Reza, MD, a fellow in the Cardiovascular Division at Penn Medicine, in Philadelphia, told Medscape Medical News.

"Going forward, I think cardiovascular educators will think deeply about how to combine the benefits of the 'hands-on' training of a traditional fellowship with the different virtual learning options we have created for continuing medical education in this environment," said Reza, who coauthored one of three papers on fellows-in-training published online April 14 in the Journal of the American College of Cardiology (JACC).

Learning in COVID-19 Valuable — Providing PPE is Adequate

In their report, Reza and her colleagues note that, whether fellows are reassigned or not due to the pandemic, opportunities for experiential learning are plentiful.

"Fellows-in-training are enthusiastically learning about cardiovascular manifestations of COVID-19, including myocardial injury, myopericarditis, heart failure, arrhythmias, and thrombophilias in real-time and through international reports," they write.

Those reassigned to noncardiology services "will be challenged with infection control, airway management, appraisal and use of experimental therapies," they add.

Fellows-in-training should further be encouraged to take part in clinical, research, and quality improvement protocols involving COVID-19.

"These experiences are valuable, so long as settings ensure proper personal protective equipment and supervision," the authors note.

Penn Medicine is among those that have declared Pandemic Emergency Status, and while that has meant that most fellows are participating in virtual programs, the training is still rigorous, Reza said.

"We have maintained only core/essential fellows at our three primary teaching hospital sites, and the majority of fellows are participating in 'at home' rotations," she said.

"These rotations include the remote reading of electrocardiograms and echocardiograms, triaging and screening clinical studies for appropriateness, and independent study/board review."


Daily teaching conferences, held via teleconference, cover broad-ranging cardiology topics, including interventional cardiology and advanced heart failure, as well as a weekly COVID-19-related conference.

And fellows are continuing to see their longitudinal outpatients via telemedicine platforms, Reza noted.

"The vast majority are performing video visits in parallel with their preceptors," she said.

"We are also exploring the use of point-of-care ultrasound and electronic stethoscope technology to augment our inpatient care delivery."

Virtual Training Experience at Brigham and Women's

At Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, in Boston, even before the pandemic, Friday morning conferences were held for all general cardiology fellows regardless of their assigned rotation, using the Microsoft Teams program, explain Zaid Almarzooq, MBBCh, and colleagues in another report in the JACC series.

"This format has been a popular aspect of our fellowship for many years as it fosters a sense of community among the fellows despite rotating at multiple hospitals," they write.

Benefits of the program have included secure cloud systems utilized by the entire healthcare system, easy collaboration, educational prompts, and the ability to conduct live polls, such as an "Image of the Week" challenge.

Their tips for successful implementation of a virtual learning platform include having a moderator to facilitate discussion in which everyone gets a chance to speak, and having a designated troubleshooter to assist when individuals have technical difficulties without disrupting the flow of the conference.

They note that "the primary challenge of this novel platform lies in the faculty's willingness to embrace this technology."

Furthermore, "it is also important to acknowledge that this does not replace the need for procedural and experiential teaching but may complement existing virtual simulation platforms," they add. 

Junior Faculty Insights

In a third report, Celina Yong, MD, director of Interventional Cardiology at the Palo Alto VA Medical Center and an assistant professor in the Division of Cardiovascular Medicine at Stanford, in Palo Alto, California, offers a personal account of her experiences and abrupt shift in her routine as junior faculty when COVID-19 came along.


"My job as an interventional cardiologist changed overnight," she writes. "Suddenly, PubMed and UpToDate no longer had the answers. I turned to Twitter discussions, where STEMI protocols developed by doctors in China started circulating."

With the only relevant data largely coming from "doctors who did not even speak the same language as me," Yong notes that she also found herself suddenly reconnecting with medical school and residence colleagues from years earlier, "exchanging hundreds of messages daily to learn from each other in real time."

"From inside make-shift parking lot tents to the cath lab, we shared our experiences as young doctors on the frontlines and supported each other through our biggest fears," she said.

"While our response to COVID-19 required social isolation, in reality, it was bringing us together in unprecedented ways."

Fellow Education is "Suffering"

Yong describes, however, a notable toll that the pandemic is taking on fellows-in-training.

"While unspoken, every trainee has recognized that fellow education is suffering," she writes.

"The volume of cath lab cases has dropped significantly — I recall just a few years ago when my interventional co-fellow and I scrambled to do every PCI possible to maximize our training," she says.

"Our current fellows will not achieve close to the numbers they need, and in the case of procedures, hands-on experience cannot be replaced.

"Yet it seems unfair to require longer training due to the pandemic."

Lessons Learned for Future Pandemics

Overall, the pandemic is providing important lessons on the shortcomings in training programs that need to be better addressed in preparing for the next one, Shashank S. Sinha, MD, medical director of the Cardiac Intensive Care Unit at Inova Heart and Vascular Institute, in Falls Church, Virginia, told Medscape Medical News

"Many programs were caught off guard," said Sinha, who coauthored a perspective on the three JACC essays entitled The Crucible of Crisis: Fellows' in Training and Early Career Cardiologists' Responses to the COVID-19 Pandemic.

Sinha noted that key questions that need to be better addressed include when and how fellows-in-training should be included; whether they should be redeployed to other roles in the event of the surge and what safeguards will be in place to ensure their safety.


"Of course, many of (those) will depend on the needs of the pandemic," Sinha said.      

However, in the current pandemic, "many fellows-in-training have also been asked to engage as frontline providers in dedicated COVID-19 units or ICUs (cardiac or otherwise)," Sinha noted.

"Their service and contributions should be applauded."