COVID-19 and Cardiology Fellowship Training: Coping With Disruption

As attention mounts around the impact of COVID-19 on healthcare workers, hospitals and patients, one group has been relatively overlooked: physician trainees. The unforeseen interruption in clinical education triggered by the pandemic threatened to have a devastating effect on residents and, to an even greater extent, fellows.

This was a major concern at Cleveland Clinic, which has 42 general cardiovascular medicine fellows and 25 fellows subspecializing in interventional cardiology, heart failure, electrophysiology, cardiac imaging and cardiology critical care. These trainees have a finite amount of time to absorb a maximum amount of information and gain proficiency in certain skills before graduating. What happens when weeks or months of training time are lost?

“Our biggest challenge is determining how to provide enough content to create the best possible trainee,” says Venu Menon, MD, Director of the Cardiovascular Medicine Fellowship Program at Cleveland Clinic.

This issue is not unique to Cleveland Clinic. Dr. Menon was one of 10 cardiovascular fellowship program directors nationwide who spelled out the impact of COVID-19 on fellowships in a recent online article in the Journal of the American College of Cardiology.

“Flexibility and innovation are needed in this highly volatile environment,” they wrote. “Programs must respond to these changes with an eye towards providing a high quality educational experience while maintaining wellness and professional growth of fellows in training.”

Prioritizing well-being

Ohio’s location at the eastern edge of the Midwest spared it from the initial devastation experienced on the East and West Coasts and allowed Cleveland Clinic to take a proactive approach to maximizing the safety of patients, staff and trainees. When the institution halted nonessential procedures and nonurgent outpatient appointments on March 18, all but the minimum number of physician trainees needed to run the hospital were sent home.

“We are responsible for the safety and welfare of our trainees,” says Dr. Menon. “Their status outside the professional staff can leave them vulnerable, so we have to protect them. Our goal has been to keep them safe while ensuring they get enough clinical experience to become good cardiologists.”

Support started at the top. “There was transparency about what we were facing,” he continues. “Staff physicians were made aware of the pressure on our fellows and encouraged to demonstrate concern for their well-being.”

“I was impressed by how our staff and fellows approached this challenge head-on, taking care of each other like a family and beginning new educational initiatives,” adds Paul Cremer, MD, Associate Director of the Cardiovascular Medicine Fellowship Program. “This was especially the case among our senior cardiology fellows, who provided a lot of leadership and direction.”

Impacts on education and research

Without the typical large volume of patients to see for a number of weeks this past spring, hands-on care was severely limited. However, a quick switch to virtual sessions meant that clinical education continued with little to no pause.

Research was impacted in a more significant way. “We couldn’t recruit patients or do the follow-ups mandated by many research protocols,” says Dr. Menon. “One large trial designed and run by fellows had to be delayed.”

However, Cleveland Clinic has taken extraordinary measures to get research projects back on track, so the impact on most fellows will be minimal.

Lucky this time

Cleveland Clinic’s cardiovascular medicine fellows were fortunate, however, because the health system resumed nonessential procedures and nonurgent visits within roughly a month and a half, allowing fellows to pick up where they had left off.

“Cath and electrophysiology lab training would have been a concern if we had remained in limbo, but the volume is back up to 90% of pre-pandemic levels as of midsummer,” says Dr. Menon. “We are quite busy, and with the high volume of patients we have, the fellows are getting typical levels of clinical experience.”

Next time, they might not be so lucky. “We prepared for a hurricane, but when the pandemic arrived, it was more like a tropical storm,” Dr. Menon observes. “If the pandemic returns in a big way, however, it is likely to affect short-duration training programs the most, both here and at other institutions. We must begin preparing for this situation now, because it’s clear we will be living with this virus for a while.”

Some bright spots…

In the past, a successful fellowship was volume-based. Now that fellowship education focuses on gaining competency, pandemic-related closings may have less impact — particularly on fast learners.

In the future, if training interruptions require a fellowship to be extended, Dr. Menon feels Cleveland Clinic will be supportive. “The funding for a few extra months won’t be allocated in advance, but I suspect we will find it,” he says.

…Along with lingering uncertainties

Every year, Cleveland Clinic receives 750 applications for cardiovascular medicine fellowship positions and invites 75 applicants for in-person interviews. Of these, 14 are accepted.

This fall, interviews will be conducted entirely virtually — a process Dr. Menon doesn’t relish. But that hurdle pales in comparison to providing medical care virtually when it’s done out of necessity rather than patient preference.

“Medicine is a contact sport,” Dr. Menon says. “We enter medicine to help people, and that help is founded on the patient-physician relationship, which is grounded in human contact. In this respect, medicine is as much one of the humanities as it is a science. We can survive with some types of care provided virtually, but it’s not ideal.”