The impact of COVID-19 on cardiology training

The coronavirus disease 2019 (COVID-19) pandemic has produced a dramatic shift in how we practise medicine, with changes in working patterns, clinical commitments and training. Cardiology trainees in the UK have experienced a significant loss in training opportunities due to the loss of specialist outpatient clinics and reduction in procedural work, with those on subspecialty fellowships perhaps losing out the most. Training days, courses and conferences have also been cancelled or postponed. Many trainees have been redeployed during the crisis, and routes of career progression have been greatly affected, prompting concerns about extensions in training time, along with effects on mental health.

With the pandemic ongoing and its effects on training likely long-lasting, we examine areas for improvement and opportunities for change in preparation for the ‘new normal’, including how other specialties have adapted. The increasingly routine use of video conferencing and online education has been a rare positive of the pandemic, and simulation will play a larger role. A more coordinated, national approach will need to be introduced to ensure curriculum components are covered and trainees around the country have equal access to ensure cardiology training in the UK remains world class.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has produced a dramatic shift in how we practise medicine, with a large reduction in specialty workload and redistribution of services to provide care for COVID-19 patients. This has necessitated changes in working patterns, clinical commitments and training for junior grades. Those in cardiology training programmes in the UK have experienced a significant loss in training opportunities, due to the loss of specialist outpatient clinics and reduction in procedural work (table 1). Trainees have traded percutaneous coronary intervention (PCI) for central lines and mechanical ventilation – a far cry from the directly observed procedural skills (DOPS) mandated by the Joint Royal College of Physicians Training Board. With the loss of these opportunities, many trainees face uncertainties about the duration of their training, fellowships and avenues of career advancement. We review how cardiology training has been affected and examine areas for improvement and opportunities for change.

The problems

Cardiology training

The most striking change to training due to the pandemic is the reduction of elective services, one of the most important areas for on-the-job training for specialist registrars. Most outpatient clinics have been switched to virtual telephone appointments, in order to reduce the number of patients attending hospital and limit the spread of COVID-19. These clinics were initially conducted by consultants without juniors, who were often rostered to cover COVID-19 wards, representing the loss of a core one-to-one training opportunity. However, as the pandemic has evolved and safety measures introduced, registrars are now also contributing to virtual clinics with consultant supervision. Elective cardiac procedures, such as diagnostic angiography and angioplasty, have also been cancelled or drastically reduced in line with national guidance,¹ which will inevitably result in delayed trainee progression. Routine echocardiography lists have also been curtailed in line with British Society of Echocardiography (BSE) guidance,² to prevent operator exposure, and recommendations for focused echocardiography offer limited opportunities for trainees to learn how to perform comprehensive scans and gain BSE accreditation.

Furthermore, most cardiology trainees have found themselves redeployed to medicine or the intensive care unit (ICU) to help in the management of patients with COVID-19. While these experiences represent valuable new learning opportunities and may enhance other skills, including leadership and team-working, exposure to cardiovascular presentations has been reduced. As emergency rotas are stepped down but preparations begin for further waves of infection, we must consider how rotas can be redesigned with education and training in mind. Scallen et al.³ highlight initiatives for neurosurgical trainees during redeployment with a rota design alternating residents between ICU and neurosurgery every two weeks to ensure ongoing exposure to their specialty (table 2). Similar ideas would be welcome among cardiology trainees.

Subspecialty trainees have also been affected by the reduced number of elective procedures, and this has produced a significant fear of deskilling. Furthermore, the documented reduction in patients presenting with cardiovascular conditions (including acute myocardial infarction),⁴ has reduced trainee exposure to acute cases and emergency complications. This corresponds with experiences from other specialties such as urology, with Amparore et al.⁵ finding between 44.2% and 62.1% of trainees surveyed had a severe reduction of their surgical activities, also noting that this affected final year trainees the hardest (table 2). This effect on more senior trainees has also been seen in cardiology programmes in the USA.⁶

Concerningly, given that all elective imaging lists were cancelled for a number of months, the subsequent backlog and longer waiting lists could mean that training lists may be sacrificed, further impacting on registrar training. Furthermore, those on fellowships, which are often undertaken around the time of training completion or after certificate of completion of training (CCT), will have had fewer opportunities to perform procedures, which may affect progression to consultant jobs. Other popular international fellowships will be unable to recruit due to travel restrictions remaining in place for the foreseeable future.

Training days and courses

Regional cardiology training days and national courses have also been cancelled or postponed, therefore, trainees have been arranging self-directed training. The increasingly routine and unprecedented use of video-conferencing software to promote virtual teaching has been a rare positive of the pandemic. Grassroots initiatives, such as the excellent online seminars initially organised by North West London trainees (https://twitter.com/cardiowebinar) have led the way and have been expanded with the help of the British Junior Cardiologists Association (BJCA) and their BJCA.tv website (https://bjca.tv), which has the ‘webinars’ recorded for later access by any trainee across the country. This is now supported by the British Cardiovascular Society (BCS) and other regional groups.

Online continued professional development (CPD) is also being developed in other specialties. Schneider et al.⁷ have advocated a greater use of distance learning in dermatology, but also argue that the pandemic should be a spur to create novel online learning platforms that can contribute to trainee education well after the pandemic. The well-recognised ‘E-learning for healthcare’ from Health Education England (HEE)⁸ has produced new courses for specialties, such as intensive care medicine, however, at the time of writing there are no known cardiology specific courses. The Royal Society of Medicine cardiology section has also started to move resources online and is offering CPD points/certificates.⁹

Conferences

The international cardiology community has been affected by reduced opportunities for professional development following the cancellation of all major international cardiology conferences, including the European Society of Cardiology Congress¹⁰ and the American College of Cardiology Conference.¹¹ Conferences are instead planning to trial an online approach, such as TCT Connect¹² and the PCR e-Course,¹³ which will include the usual mix of scientific presentations, lectures, and live cases. Indeed, this approach may benefit as attendance, travel and accommodation costs will be negligible, and trainees may find participation easier, despite on-call commitments. However, the professional networking and social benefits of such events would remain lost.

Career progression

Cardiology trainee progression has also been affected with Annual Review of Competence and Progression (ARCP) in most deaneries being significantly delayed or undertaken remotely. While some have had truncated telephone reviews, many have been left without these comprehensive sources of in-depth feedback and confirmation that curriculum competencies are being developed appropriately. Many trainees have struggled to get supervised learning events (SLEs) and DOPS completed during this time, especially for specialty specific competencies. Others may still be mandated an extension in training time if competences have not been met.¹⁴

In a blow for those earlier in their cardiology careers, interviews for specialty training (ST3) recruitment have been cancelled in most areas, with a controversial reweighting of initial interview scores used instead, which has created frustration for many who have been unable to gain posts. The HEE model used has been detrimental to many prospective cardiologists, most of whom have well-developed curricula vitae resulting in a ‘clustering’ of higher scores and reducing discrimination between well-qualified candidates.¹⁵ There has also been no assessment of other skills or experience, such as echocardiography and catheterisation laboratory work, or commitment to specialty.

Mental health

Mental health concerns and burnout are also likely to greatly impact cardiology trainees. A combination of redeployment from the known specialty, extended workloads and anxiety related to morbidity and mortality from COVID-19, may produce both long- and short-term complications that have not been adequately addressed.¹⁶ Shah et al.¹⁶ propose numerous solutions, but include a focus on ensuring breaks, a limit to work hours in emergency and intensive care units, and the provision of regular psychosocial support, essential basic needs (e.g. meals), mindfulness sessions and resilience training. Many centres have provided some or all of these over the initial phase of the pandemic, and we hope that these initiatives will be continued as a positive change to our working lives.

The new normal

Despite the gradual reintroduction of some elective services, it is likely that the pandemic will affect training for some time to come. Kohan et al.¹⁷ summarised a meeting of programme directors who felt the effect of COVID-19 on training was going to be “long standing and deep”. A long-term transition to online training would require significant effort, investment and further research. Although the ad-hoc resources produced locally and regionally have been successful, a more coordinated, national approach will need to be introduced to ensure curriculum components are covered and trainees around the country have equal access. This should ideally be conducted at the level of national societies to ensure standardisation of teaching programmes, as has happened in other specialties.⁷

It is important to recognise that online courses and lectures via video conferencing have been found to be non-inferior to face-to-face teaching.¹⁸ If face-to-face teaching can resume, the frequency of sessions may have to change with daily or regular short online lectures, rather than large training days and multi-day courses. Newer rotas and distancing requirements may mean that many remain unable to attend, as lecture and conference facilities are not yet designed or modified to undertake reasonable social distancing, and fears may persist of spreading the virus throughout the entire audience.

Yuen et al.¹⁹ recommend three aspects of focus for medical trainers during the pandemic (and afterwards); preparation of revision materials for professional examinations, facilitating practical skills and clinical procedures with simulation and augmented or virtual reality, and encouraging reflection on the skills learned during the crisis. These steps can be adapted to clinical cardiology along with other possible solutions outlined above (table 3).

Simulation training is already well established in cardiology,²⁰ with training days for new registrars already highly recommended by the BCS and training programme directors. Computer-based simulation resources are available, mainly for angiography, but also for transthoracic and transoesophageal echocardiography, though pacing/devices have fewer readily available options. Resources will need to be greatly expanded and more widely utilised, which will require investment and time. Social distancing may result in a reduction of doctors who can participate on a given course, but an expansion in these simulation sessions may ameliorate the reduction in hands-on experience. García-Lozano et al.²¹ highlight how simulation can be continued and further enhanced via video conferencing, with trainers providing feedback remotely (table 2). Unfortunately for procedural subspecialties, trainees may have to continue their training for longer periods, which may reduce available training numbers. Indeed, this is also the case in the US, where future job openings and current job offers are in doubt after the withdrawal of some offers.⁶

Conclusion

Cardiology training for specialist registrars has been greatly affected by the COVID-19 pandemic, further heightened due to the significant procedural component. This presents new opportunities for an expansion of remote and online training, but also challenges for ensuring high-quality, coordinated and appropriate resources are accessed. While locally produced ad-hoc resources have started to address some of these gaps, many of these changes may be longer-lasting and deeply rooted than initially hoped. The pandemic will affect services for some time, and we must continue to innovate to help reduce the impact of reduced procedural work on trainee progression. Learning how other specialties and other countries are adapting will be essential to ensure cardiology training in the UK remains world class.

Key messages

• Cardiology trainees in the UK have experienced a significant loss in training opportunities due to the loss of outpatient clinics and procedural work
• The effects of the pandemic will be long-lasting, and we must examine potential solutions to help reduce the impact of reduced opportunities on trainee progression
• Video conferencing and online education have been a rare positive of the pandemic, and simulation will play a larger role
• Learning how other specialties and other countries have adapted will be essential to ensure cardiology training in the UK remains world class

Conflicts of interest

None declared.

Funding

None.

References

1. British Cardiovascular Society (BCS) and British Cardiovascular Intervention Society (BCIS). BCS & BCIS Joint statement regarding cardiology services during COVID-19. Available at: https://www.britishcardiovascularsociety.org/news/bcs-bcis-cardiology-services-during-covid-19 [accessed 4 June 2020].

2. British Society of Echocardiography. Clinical guidance regarding provision of echocardiography during the COVID-19 pandemic. Available at: https://www.bsecho.org/Public/Education/COVID-19-clinical-guidance.aspx [accessed 3 June 2020].

3. Scullen T, Mathkour M, Maulucci CM, Dumont AS, Bui CJ, Keen JR. Impact of the COVID-19 pandemic on neurosurgical residency training in New Orleans. World Neurosurg 2020;139:718–19. https://doi.org/10.1016/j.wneu.2020.04.208

4. Wu J, Rashid M, Weston C et al. Patient response, treatments and mortality for acute myocardial infarction during the COVID-19 pandemic. Eur Heart J Qual Care Clin Outcomes 2020. https://doi.org/10.1093/ehjqcco/qcaa062

5. Amparore D, Claps F, Cacciamani GE et al. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol 2020;72:505–09. https://doi.org/10.23736/S0393-2249.20.03868-0

6. Goel S, Sharma A. COVID-19 pandemic and its impact on cardiology and its subspecialty training. Prog Cardiovasc Dis 2020;63:525–6. https://doi.org/10.1016/j.pcad.2020.05.004

7. Schneider SL, Council ML. Distance learning in the era of COVID-19. Arch Dermatol Res 2020;1-2. https://doi.org/10.1007/s00403-020-02088-9

8. Health Education England. Home – e-Learning for Healthcare. Available at: https://www.e-lfh.org.uk/ [accessed 21 June 2020].

9. Royal Society of Medicine. Cardiology section. Available at: https://www.rsm.ac.uk/sections/cardiology-section/

10. European Society of Cardiology. ESC Acute Cardiovascular Care 2021. Available at: https://www.escardio.org/Congresses-&-Events/Acute-Cardiovascular-Care [accessed 3 June 2020].

11. American College of Cardiology. ACC.20/WCC in Chicago is Canceled. Available at: https://www.acc.org/about-acc/press-releases/2020/03/09/08/43/acc20-wcc-in-chicago-is-canceled [accessed 3 June 2020].

12. Cardiovascular Research Foundation. TCT 2020. Available at: https://www.crf.org/tct [accessed 4 June 2020].

13. PCR online. PCR e-Course 2020 – Quick view. Available at: https://www.pcronline.com/Courses/PCR-e-Course/Programme/Programme-Quick-View [accessed 4 June 2020].

14. Joint Royal Colleges of Physicians Training Board. ARCPs during Covid-19 pandemic: specific specialty advice for medical specialties. Available from: https://www.jrcptb.org.uk/sites/default/files/Specific%20specialty%20advice%20for%20ARCPs%20updated%20070520.pdf

15. Bradley-Watson J, Samways JW, Allen CJ, Kotronias RA. Understanding trainee physician speciality recruitment during COVID-19: insights from a trainee led survey. British Cardiovascular Society, 2020. Available from: http://www.bcs.com/documents/BJCA_ST3_Report_Final_Clean_BJCA_09_06.pdf [accessed 17 August 2020].

16. Shah K, Chaudhari G, Kamrai D, Lail A, Patel RS. How essential is to focus on physician’s health and burnout in coronavirus (COVID-19) pandemic? Cureus 2020;12:e7538. https://doi.org/10.7759/cureus.7538

17. Kohan L, Sobey C, Wahezi S et al. Maintaining high quality multidisciplinary pain medicine fellowship programs. Part II: innovations in clinical care workflow, clinical supervision, job satisfaction and postgraduation mentorship for pain fellows during the Covid-19 pandemic. Pain Med 2020:pnaa176. https://doi.org/10.1093/pm/pnaa176

18. Chipps J, Brysiewicz P, Mars M. A systematic review of the effectiveness of videoconference-based tele-education for medical and nursing education. Worldviews Evidence-Based Nurs 2012;9:78–87. https://doi.org/10.1111/j.1741-6787.2012.00241.x

19. Yuen J, Xie F. Medical education during the COVID-19 pandemic: perspectives from UK trainees. Postgrad Med J 2020;96:432–3. https://doi.org/10.1136/postgradmedj-2020-137970

20. Barakat K. The role of simulation-based education in cardiology. Heart 2019;105:728–32. https://doi.org/10.1136/heartjnl-2017-311153

21. García-Lozano JA, Cuellar-Barboza A, Garza-Rodríguez V, Vázquez-Martínez O, Ocampo-Candiani J. Dermatologic surgery training during the COVID-19 era. J Eur Acad Dermatology Venereol 2020:jdv.16621. https://doi.org/10.1111/jdv.16621