COVID-19 pandemic and its impact on cardiology and its subspecialty training

To the Editor

Coronavirus disease, or commonly known as COVID-19, has overwhelmed the healthcare system around the globe at an unprecedented level. Since the first reported case in Wuhan, China,¹ 212 Countries and territories around the world have reported 3,672,238 confirmed cases with a total death toll of 254, 045 (as of May 7th 2020).² The United States (US) is now the new epicenter of this pandemic with highest number of confirmed cases (1,219,066) and deaths (73,297).³ All medical services across the country, including cardiology, have been severely disrupted and will be for at least several months. This article delineates the challenges currently being faced by cardiology and subspecialty fellows in this tough time.

Impact on training

With American College of Cardiology and Society for Cardiovascular Angiography and Interventions recommending deferral of elective cardiac, endovascular, or structural catheterization procedures during the COVID-19 pandemic,⁴ elective cases normally done by fellows have been postponed or canceled across the country. Similarly, other cardiology societies^{5 , 6} are recommending deferring or canceling non-emergent procedures and imaging studies, leading to a drastic decrease in the procedure and patient volume. On the other hand, there are reports of the decline in the number of patients presenting with acute coronary syndromes in regions severely affected by the pandemic.⁷ To make the situation grim, current projections predict that this trend is expected to continue for several months.

Cardiology and subspecialty fellows are being actively deployed as attending physicians or fellows/resident physicians in emergency rooms, medical floors or critical care units to care for COVID-19 patients. The fellows deployed are working mostly on rotating shifts basis in line with current clinical demands, to limit virus exposure and to keep the workforce reserve. Mostly on-call fellows and attendings are managing the cardiology services in the hospital, which are limited mostly to in-patient consultation and emergent procedures. The Mount Sinai Cardiac catheterization laboratory, one of the busiest in the country performing hundreds of elective cases per month, has come to a complete standstill.

The Accreditation Council for Graduate Medical Education (ACGME) recognizes that fellows training in cardiology and other subspecialty are expected to achieve the necessary cognitive and technical skills for independent practice. For fellows training in interventional cardiology and cardiac electrophysiology as a procedural specialty, minimal procedural volumes are required of fellows to ensure the development of appropriate technical skills.⁸ With the ongoing pandemic, which has curbed the entire US, it is clear that, at least during the remainder of the 2019–2020 academic year, most fellows will not be able to accomplish clinical rotations, procedure volumes and patient care encounter as outlined in the ACGME program requirements for graduate medical education in cardiovascular disease. The impact of these deficient experiences will be greatest on fellows in their final years of training and, especially, this being the final quarter of the academic year, the fellows are expected to make independent decisions and consolidate the cognitive skills, which they have acquired over the past year. The American Board of Medical Specialties (ABMS) and the ACGME have already recognized that trainees might not be able to achieve the minimal specialty-specific case requirement in the current year.⁹

Impact on education

Due to clinical demands and need for social distancing, the clinical and educational conference schedules planned by programs for the current academic year, which were to be in effect at this time, have been severely impacted. Many of these conferences and meetings either have either been canceled or are being held remotely, if at all. Also, social distancing measures have forbidden the old-fashioned trainee-faculty in-person teaching.

A growing number of cardiology conferences around the globe are either being postponed, canceled or being conducted virtually to prevent mass gathering and heath care workers transmitting the very same virus that they are fighting against.¹⁰ These measures have resulted in diminished learning and circumventing collaborative and networking opportunities for trainees. Similarly, research has been suspended at many institutions with core laboratory closures and institutional board review mandating to stop in-person participant visits to prevent the spread of the virus. This pandemic could disrupt the years of hard work put by physician-scientist and adversely affect grant funding for the ongoing studies.

Although the educational opportunities are severely limited in this time of crisis, especially in-person mentoring, in this age of technology there are ample online educational tools and resources available to the trainees to learn and enrich themselves. In addition, with on and off rotational policy, fellows can get more time to engage with their mentors remotely to confer new projects, write grants for future studies, and resume pending projects.

Impact on personal life

The current COVID-19 pandemic is taking an enormous toll on the physical and psychological wellbeing of cardiology and its subspecialty trainees. During these difficult times, a physician's family is paramount to maintaining optimal mental health while facing the precariousness of COVID-19. However, due to a nationwide shortage of personal protective equipment (PPE), inadequate testing, limited treatment options, and extended workloads, trainees are deeply concerned that they may contract the illness and expose their family members at home, who may be more vulnerable to the virus. This has led some physicians to distance themselves from their family and remain in a separate room or home and only see their family through the window or by video calling. As the front line providers, fellows are also succumbing to illness, with many being quarantined due to exposure to the virus or recovering from COVID-19 infections themselves.

The economic side of this pandemic is also alarming to many fellows, carrying huge sums of medical school debts and with limited stipends and savings exposing their vulnerability. With hospitals and private practices reducing elective procedures and outpatient visits, there will be lost revenues, which is unlikely to be recovered given the current projections of the pandemic. With a loss in savings, many hospitals and practices are curtailing new hires, withdrawing offers and reducing the reimbursement to the physicians who will be unable to meet the productivity target for this fiscal year. Given this outlook, fellows are concerned about the security of existing job offers and the likelihood of future job openings.

The impact of COVID-19 on cardiology and its subspecialty training programs has been profound. With no end in sight, no one yet knows how severely the US will be impacted by the current pandemic. In these difficult times, we fellows as a community should stay strong, informed and create solutions to tackle these unprecedented challenges. “This too shall pass”.

Statement of conflict of interest

None of the authors have any conflicts of interests with regard to this publication.