|NARRATIVE MEDICINE SYMPOSIUM ON COVID-19: INDIVIDUAL CONTRIBUTIONS
|Year : 2020 | Volume
| Issue : 2 | Page : 153-155
Interventional cardiology in the times of coronavirus: A fellow's perspective
Qasim Z Malik, David Prutzman
Department of Cardiology, St. Luke's University Health Network, Bethlehem, PA, USA
|Date of Submission||22-May-2020|
|Date of Acceptance||07-Jun-2020|
|Date of Web Publication||29-Jun-2020|
Dr. Qasim Z Malik
St. Luke's University Health Network, Bethlehem, PA
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Malik QZ, Prutzman D. Interventional cardiology in the times of coronavirus: A fellow's perspective. Int J Acad Med 2020;6:153-5
As the coronavirus pandemic unfolds, we have seen unprecedented times all over the world. At the time this article was written, more than 5 million people all over the world had tested positive, while more than 300,000 fatalities attributed to this virus had occurred all over the world. The virus has affected all segments of every society, the international economy, and global healthcare.
Arguably, one of the most affected communities by the ongoing pandemic has been the healthcare community, as evidenced by not just physician and/or nursing short-staffing but the shortage of personal protective equipment and the resulting physical and emotional toll of managing an overwhelmed hospital system. As no one is immune to the effects the pandemic is having, medical education has also suffered, though rapidly evolving.
Residency/fellowship programs have switched to virtual didactics via various platforms to be able to teach trainees who are the most vital stage of their careers. With the sudden and rapid growth of tele-medicine during the course of the pandemic, tele-health is being incorporated more into continuity clinics for trainees nationwide.
Not surprisingly, my postdoctoral research fellowship has also been affected by the events, as I have now gotten used to “working from home” over the past 2 months. Through the daily events, I anxiously follow social media platforms to learn more about the virus and its effects, particularly on my upcoming interventional cardiology fellowship training, and speak to friends/colleagues in various training programs to get more insight into the possibilities as I start a new, probably most vital chapter in my training.
As part of the nationwide pandemic response, the CMS recommended hospitals cancel all elective procedures, and this continued until May 11 in the St. Luke's University Health Network. While things are now slowly improving, we are far from even the “new normal,” while harboring ongoing fears of a “second wave.”
The cancellation of elective procedures has directly affected interventional cardiology training programs nationwide and has had a rather two-pronged effect. First, elective cardiac catheterizations and other procedures done in the cardiac catheterization laboratory make the bulk of the procedures performed, and the cancellation of these has deprived trainees of vital experience in the last few months of their training. As interventional cardiology is a 1-year training program as per the Accreditation Council for Graduate Medical Education (ACGME), this translates into a roughly a quarter of a fellow's training. Second, as reported, the “fear factor” associated with COVID-19 has caused patients to delay seeking care for cardiac symptoms. Hence, the incidence of myocardial infarctions has significantly decreased. I regularly see on my twitter feeds, reports of patients who presented to the hospital “too late,” indicating that it is the fear factor which is preventing patients from seeking the care they need urgently. While this, of course, harms patients the most as potentially treatable problems become more complicated due to the delay in care, this has further reduced the case volume in cardiac catheterization laboratories all over the United States.
The ACGME requires 250 coronary interventions to be performed for a trainee to have successfully completed training in interventional cardiology  and be board eligible with the American Board of Internal Medicine (ABIM). Given the unique situation that we are in, where a sizable number of trainees may be struggling to meet this target at the end of the academic year (June 30, 2020) due to the reasons mentioned above, ABIM has determined that the graduating fellows may take 3 more months to maximize their training at the end of the year; however, if deemed “competent as an interventional cardiologist” by their training program, they will be allowed to sit for the board examinations. While that is reassuring as a trainee, nothing can make up for the experience one has with hands-on training, and it is most relevant in procedure-based specialties.
Gupta et al. recently published their findings from web-based survey of 21 interventional cardiology training programs in the New York Metro Area, which has been most hardly hit by the pandemic. Seventy-one percent of fellowship program directors and 95% of current interventional cardiology fellows thought that their fellows' training has been at least “moderately” affected due to the pandemic, with 21% of program directors saying their fellows would not be able to meet the standard of 250 coronary interventions by the end of their training. A quarter of interventional cardiology fellows reported having less than 250 coronary interventions as of March 1, roughly the time when the surge of cases occurred, leading to the nationwide lockdown, and suspension of elective cases.
Structural interventional cardiology constitutes an important part of interventional cardiology training. While, over the last few years, structural interventional cardiology has grown to be an independent 1-year unaccredited training due to the complexity of those procedures, trans-catheter aortic valve replacement (TAVR) still remains an important part of training for interventional cardiology fellows training in programs that offer it as part of the traditional 1-year fellowship. While there are no data yet to tell us about the effects the pandemic has had one TAVR volume for TAVR centers or for trainees, it is safe to assume that those have been adversely affected as well.
With no clear end of the pandemic in sight, the above figures and thoughts make me anxious about my upcoming interventional cardiology fellowship. While I am fortunate in the sense that I am already a part of the health system that I will be training in, with no need to move or acclimatize to a new environment, I do feel for the many thousands of residents/fellows who will be needing to move to start their training at the end of June 2020. However, the pandemic is also having never seen before the effects on hospitals and physician practices nationally. The fact that everything about the pandemic is “never seen before” contributes to the uncertainty associated with the future. Being a 1-year fellowship, interventional cardiology fellows tend to look for jobs right from the beginning of their training, as finding the right job is quite a tedious process. That means it will be time for me to look for jobs in this environment of uncertainty as I begin my training in July 2020.
Having no clear answers or knowing what to expect from all of this, I turn to my friend and colleague, David Prutzman DO, who is currently doing his interventional cardiology fellowship at the St. Luke's University Health Network. He has been looking for jobs through the pandemic and has seen procedural volumes go down as the pandemic surged in the Lehigh Valley.
Dr. Prutzman told me that he had met the requirement of 250 coronary interventions and the recommendations for training in TAVR before the pandemic surge and subsequent cancellation of elective procedures. While his training had definitely suffered, he has managed to regularly be participating urgent/emergent coronary interventions, albeit at a reduced rate compared to the “Pre-COVID era”. In the last few weeks of his training, he is very confident and feels adequately trained to practice independently as an interventional cardiologist. He does mention how the events of the last few weeks have made him value his career choice more than ever before.
As all strata of the economy react and adapt to the pandemic, we are yet to see its after-effects, though we are all experiencing its effects. This did adversely affect Dr. Prutzman's job search as health systems wait to see the true financial implications of COVID-19. He now looks forward to his new job to begin in July 2020, which he had fortunately interviewed for before the recent events.
Amid the uncertainty of these times, I now find myself well positioned to start my interventional cardiology fellowship. The leadership of St. Luke's Cardiology has managed to maintain the quality of training for its fellows in times never experienced before.
I find reassurance in Dr. Prutzman's experience, and as my anxiety abates, the pandemic is slowly but surely slowing down and life is creeping toward an unknown “new normal.”
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The authors of this manuscript declare that this scholarly work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network (http://www.equator-network.org). Within the broader context of narrative medicine, this article discusses individual stories and patient encounters as integral aspects of the lived experience of health and illness.
| References|| |
Krumholz HM. Where have all the heart attacks gone? New York Times; 6 April, 2020.
Gupta T, Nazif TM, Vahl TP, Ahmad H., Bortnick AE, Feit F, et al
. Impact of the COVID-19 pandemic on interventional cardiology fellowship training in the New York metropolitan area: A perspective from the United States epicenter. Catheter Cardiovasc Interv 2020;16:1-5.
Garcia S, Albaghdadi MS, Meraj PM, Schmidt C, Garberich R, Jaffer FA, et al
. Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic. J Am Coll Cardiol 2020. [Ahead of print].