Clinical Editor's Corner: Kern

On Teaching Cardiac Cath Part II: Where is Your Attending?

Compiled by Morton J. Kern with contributions from: Robert Applegate, Winston-Salem, North Carolina; David Cohen, Kansas City, Missouri; Larry Dean, University of Washington, Seattle, Washington; Andrew Doorey, Christiana Hospital, Newark, Delaware; Kirk Garrett, Lenox Hill, New York City, New York; John Hirshfeld, University of Pennsylvania, Philadelphia, Pennsylvania; Lloyd Klein, Chicago, Illinois; Mitch Krucoff, Raleigh, North Carolina; Gus Pichard, Washington, D.C.; Mike Ragosta, University of Virginia, Charlottesville, Virginia; Molly Szerlip, Dallas, Texas; Barry Uretsky, University of Arkansas, Little Rock, Arkansas; George Vetrovec, Medical College of Virginia, Richmond, Virginia; Bonnie Weiner, University of Massachusetts, Worcester, Massachusetts; Alan Yeung, Stanford University, Stanford, California.

Compiled by Morton J. Kern with contributions from: Robert Applegate, Winston-Salem, North Carolina; David Cohen, Kansas City, Missouri; Larry Dean, University of Washington, Seattle, Washington; Andrew Doorey, Christiana Hospital, Newark, Delaware; Kirk Garrett, Lenox Hill, New York City, New York; John Hirshfeld, University of Pennsylvania, Philadelphia, Pennsylvania; Lloyd Klein, Chicago, Illinois; Mitch Krucoff, Raleigh, North Carolina; Gus Pichard, Washington, D.C.; Mike Ragosta, University of Virginia, Charlottesville, Virginia; Molly Szerlip, Dallas, Texas; Barry Uretsky, University of Arkansas, Little Rock, Arkansas; George Vetrovec, Medical College of Virginia, Richmond, Virginia; Bonnie Weiner, University of Massachusetts, Worcester, Massachusetts; Alan Yeung, Stanford University, Stanford, California.

In early July, I wrote about how we should help the new cath lab trainee to “see” the patient and better understand how teachers of the procedure could improve learner interactions. This conversation expands on the role of the attending physician as a supervisor for teaching cath lab trainees. As with earlier conversations in cardiology, I want to extend my thanks and appreciation to my contributing expert colleagues for their contributions. 

The question:  Where is your attending?

Dr. Andrew Doorey from Christiana Hospital, in Newark, Delaware, asked our experts about the supervision of cardiology fellows in the catheterization laboratory. “I always scrub with the fellows, watch their actions very carefully, make sure even the small points are done correctly, and provide some advice or suggestion, especially if the case is not totally straightforward. We have some attendings who not only don’t scrub, but don’t even come into the room. They will often sit outside at the monitoring bench, talking on the phone, or checking email on a computer. They look up from time to time to see how the case is progressing. At times, they are not even in scrubs. I think this is inappropriate. Fellows don’t learn from them, patients may be at risk, and the fellow is weakly supervised. [With closer attention] some complications may have been preventable. I am told that ACGME [Accreditation Council for Graduate Medical Education] has no specific requirements about this. Our risk management people told me that their understanding of attendings and trainees is that the attending is prepared to “immediately take over”. To me, this would suggest that the attending should be scrubbed next to the fellows. But the practice continues.  

“Am I being too compulsive about this? Or do people think it’s okay for the attending to be outside in the monitor area, intermittently engaged in other activities while trainees do cases?”

One approach:  Graded involvement

Mort Kern, Long Beach, California: My view is that the attending should always be present and ready to step in.  For early year trainees, he should scrub in with them. With 3rd-year fellows ready to go into practice and whom he knows well, the attending can observe from the control room. The attending should be observing closely and ready at all times to step in and render immediate assistance. For interventional fellows, he should be scrubbed for at least three quarters of the year and then, when confident of the fellow’s abilities, he can step back, but not be far away. There are some programs where the attending designates a senior and junior fellow to do the case, and the attending only gets involved for billing purposes. This may be acceptable if the senior fellow has the complete confidence of the attending and is considered a good teacher.

David Cohen, Kansas City, Missouri: Early on in the year, I scrub, because the fellows need to learn good habits early. Later in the year, I will let a more senior fellow supervise a first-year fellow with me close at hand — watching what is going on carefully. For PCI [percutaneous coronary intervention], I always scrub, but the role of the fellow progresses to where they do more and more of the case as the year and their skill progresses.  

Mike Ragosta, Charlottesville, Virginia: At the University of Virginia (6 interventional cardiologists), all 6 of us scrub and are at the table with all fellows from the ‘time out’ and the injection of local anesthetic. We watch every step for every fellow, regardless of the level. You would be amazed at how often “advanced” or “senior” fellows forget basic steps like flushing a sheath, advancing a catheter with the J wire ahead of the catheter tip, or paying attention to catheter pressure waveforms when engaging a coronary. We believe fellows learn good habits this way. Of course, as their skills progress, they do more and more without needing our input, but have learned very good habits from the beginning and continue to learn when things become more challenging. I’m sure there are lots of ways to do it, but we feel this is optimal for the balance of patient safety and education.

Lloyd Klein, Chicago, Illinois: I agree with David Cohen’s approach. I’d add that I always scrub. I am at the table in every case, even “routine” or “easy” ones. With the more advanced senior fellows who are going to make the lab their career, I might not even touch the equipment, but I am making suggestions and always participating. I had attendings who took a more hands-off approach, even a few in this conversation, and I was always pleased that they did so, but when I became an attending, it amazed me how fast things can turn ugly.

Mitch Krucoff, Raleigh, North Carolina: In early days of over-the-wire [percutaneous transluminal coronary angioplasty, PTCA] systems, we always scrubbed. To this day, I still teach that the very best approach to invasive work is “4 hands, one mind” at the table. That said, with rapid exchange systems and easy use instruments we have today, I have become more comfortable with a “graded” system, similar to what Mort describes. Depending on the fellow, and on their experience level, I am always ready, but as the year moves forward from July, I am progressively more in the control room. This approach is widely practiced across Duke attendings. One thing I learned based on feedback from the fellows about our program each year is that the fellows find it valuable to feel like they are really running the case (even though they know the attending is in the control room). 

There have been occasional fellows who I just didn’t trust, and never let them scrub alone. I always scrub on all STEMIs [ST-elevation myocardial infarctions], no matter how good or experienced the fellow is. Lastly, I always scrub if we are using new technology, like the CSI orbital atherectomy device, a scaffold, etc. To me the priorities are 1) protect the patient, and 2) provide a learning experience for the fellows. In my 3rd decade of doing this, I am comfortable that it is not a one size fits all approach, and that the commitment to a teaching program requires us to be flexible as to what is “optimal” for teaching not only skills, but also independence.

Gus Pichard, Washington, D.C.: At the Medstar Washington Hospital Center, the rules have changed. We presently have 18 cardiology fellows and about 6 interventional fellows. This size program makes it impossible to have the same fellow rotating with one attending for many months at a time, so the progression to total independence at the table is different. In addition, new lab rules require that the attending be “in the lab” for time out and results in all attendings being scrubbed for all cases.

George Vetrovec, Richmond, Virginia: The first responsibility is to the patient! That patient is in your hands, sometimes even by referral from the patient (himself) or a colleague. He deserves your best skill which is what he came for; so not to be present to be sure he gets what is your practice level is inappropriate and I would suggest immoral. 

That said, I have trained fellows for close to 4 decades, and I understand their need to learn and become independent. But they benefit from repetition of good techniques, which only comes from an attending at their side or very near by as their experience progresses. Time to greater independence is fellow-dependent, and should be individually assessed and allowed as appropriate. Patient safety and optimal outcome remains the guiding principle. Some fellows require supervision to the end of their training, but this just reflects skill and training variability. Fitting the fellow to a prescribed “training nomogram” may not be fair to the patient if the fellow is not yet of that caliber! This [caution] is for the fellow’s good regarding education and certainly meets your patient obligation. 

Two other thoughts:

  1. Having more senior fellows supervise more junior fellows abrogates attending responsibility for teaching and in the case of a problem, the attending will try to blame the problem on a trainee, which is inexcusable! While there may be some teaching experience for the more senior fellow, it is not sufficient to abrogate attending responsibility, patient outcome, and potentially, fellow blame.
  2. Billing is billing. Anything other than attending presence for the key portions of a procedure or supervising multiple procedures at the same time is fraud!

At the end of the day, what would you want for your mother if she were undergoing cath by a trainee? The same is true for all patients.

Bonnie Weiner, Worcester, Massachusetts: George, I agree with your ‘fellow teaching fellow’ comments. I find that all this does is perpetuate bad habits, particularly in a situation where there are diverse experience levels even among the attendings. I agree that it is “my” responsibility to teach in this situation. Even using the interventional fellows [as teacher], who presumably will be practicing as cath attendings if they weren’t doing advanced fellowships, doesn’t really provide the best supervision and training for the more junior trainees.

Larry Dean, Seattle, Washington: I scrub on 99.9% of the cases, irrespective of the trainee level and continue to teach at a level appropriate for the trainee.

Barry Uretsky, Little Rock, Arkansas: I agree with most of my colleagues and have a few points I want to emphasize. First, to respond directly to Dr. Doorey’s question, I do not think that the attending is required to be scrubbed and at the table for every part of every case. It should be dictated by the level of competency of each fellow, which requires that the attending know this information. If the attending does not, then table-side training is required. We use a case-by-case and fellow competency approach to determine the extent of the attending being scrubbed at tableside. If the attending is not at tableside, then he/she is observing the case either in room or in the control room. Our primary dictum is that optimal patient management is paramount. Any approach to fellow training in diagnostic/interventional procedures must be compatible with optimized patient care and safety. 

It is not unusual that fourth-year interventional trainees have technical and knowledge gaps, or inexperience with some aspects of the fundamentals of diagnostic catheterization. Thus, fourth-year training may be thought of as a “finishing school” to master basic cath techniques. In our lab, when the interventional fellow is not engaged in an intervention, he/she frequently oversees the junior fellow with the attending observing from the control area. This approach has worked for us in providing the interventional trainee (who is supposed to be already capable of performing independent cath) with improving technique under attending supervision, albeit at a distance. I also believe that every attending on this e-mail chain has an “internal clock” as well as direct observation skills to know when to take over, so that being in the control room in selected cases has not been problematic in our view. For interventional cases, all attending are scrubbed throughout the case.

We also spend a lot of time with our fellows prior to the every case, reviewing all aspects of the patient’s history and previous procedures. I continue to be surprised how frequently our fellows do not know important aspects of the patient’s previous procedures or relevant medical issues. Training fellows to be compulsive about the patient’s condition prior to the procedure is an important [but sometimes overlooked – MK] function of our teaching.  

Molly Szerlip, Dallas, Texas: I have always done what Mort does [WWMD? Thanks – MK]. For the first and second years, or third years that I don’t yet trust, I am at the table and scrubbed. For those fellows who are experienced and that I do trust, I will be in the control room, especially if they plan a career in intervention. I think it is just as important to be able to work “independently” before going to an interventional fellowship. At Beaumont, we were expected to be able to do all diagnostics by ourselves without attending presence at all. For some of my fellow colleagues, this was a shock. Things can turn ugly fast, but the attending should always be ready to jump in when needed.

Alan Yeung, Stanford, California: Over the last 2 decades, I have pretty much stuck to the same system: 1) Diagnostic right and left heart caths: for general cardiology fellows, the attending is next to fellow from puncture to closure. No techs or nurse scrubbed. With more and more radials, it is even more important to be there with proper identification of pulse and landmarks. How much the fellow will do depends on their skill and experience. I go over the findings right after and reports are generated soon after the procedure. During the second part of the year, the interventional fellow may occasionally serve in the attending role, with the attending being the third person at the table supervising both fellows.  2) RV biopsies are performed only by interventional fellows under close supervision.  3) PCIs are done with an interventional fellow and attending. 

Bob Applegate, Winston-Salem, North Carolina: I am bothered by an attending who sits in the control room and often has to shout out commands during the procedure, which cannot do much for the patient’s confidence if the patient is at all “conscious”. Comments from former general and interventional fellows remind us that the things “whispered” in their ears by me (or any attending) while scrubbed next to them stuck with them and are as meaningful as anything else they took away from training.

John Hirshfeld, Philadelphia, Pennsylvania: For first- and second-year fellows, we downplay training in technical skills, particularly for fellows not intending to go into cath/intervention. The focus is on their learning the cognitive aspects of hemodynamic and angiographic data acquisition and interpretation.  Thus, we do not permit first- and second-year fellows to spend any important amount of time struggling to perform a maneuver. We make clear to them that learning technical skills is not the mission of the first and second year, and we do not think it justifiable to subject patients to extra time, discomfort and radiation to provide unnecessary fellow education.

As noted by Mike Ragosta, in order to maintain consistently safe practices, we hound third- and fourth-year fellows on technique, particularly the multiple rituals such as sheath flushing, guide wire usage, pressure monitoring, etc., that enhance safety. We find that there is a continual battle to prevent erosion of these safety practices, as they only make a difference in the decimal point of complication rates. Thus, when a trainee has several hundred cases in his/her experience and has not had any serious complications, he/she does not have a framework of reference to understand the importance of the various safety rituals, not yet having experienced a complication caused by corner cutting.

The educational role of the attending in scrubbing with both junior and senior fellows cannot be overemphasized. While there is certainly a role for a trainee learning by struggling to solve a problem on his/her own, frequently the ongoing counsel of an experienced person is more valuable in learning. I think that the challenge to being a trainer is to be able to talk an inexperienced trainee through a complex maneuver by describing in words how to execute the maneuver that the trainee is struggling with. This challenges the trainer to understand the situation and the execution of the maneuver well enough to describe the technique verbally, with sufficient clarity that the trainee can successfully perform it by applying the verbal guidance. This requires that the trainer have sufficient personal understanding to be able to explain both how to execute the technique and why the technique succeeds. This is much more challenging than defaulting to “I’ll do it, watch how I do it.” In general, third- and fourth-year fellows are not as proficient at this as senior faculty.

George Vetrovec, Richmond, Virginia: I can’t agree more and I have heard the same from my prior fellows. In fact, one fellow told me in his first day in practice that he kept listening for the voice with instructions and thought he heard it! What more could I have done for his success!

Bob Applegate, Winston-Salem, North Carolina: Likewise, when we hear the same thing from multiple fellows, I tend to believe it. And we have exactly the same feedback. While many attendings say the fellows appreciate “being given the reins” in the lab, the majority of fellows remember our whispers much more than anything else.

Kirk Garrett, New York City, New York: In defense of those with a more liberal take, I have to point out that current training guidelines require fellows entering interventional programs to have completed COCATS II training [The American College of Cardiology’s Adult Cardiovascular Medicine Core Cardiology Training], which means competency in diagnostic cath. We should expect that providing “finishing school” touches will be needed early in the year, but these fellows would already be eligible for invasive/non-interventional privileges at your hospital, so it’s reasonable to expect them to perform diagnostics at a competent level.

Barry Uretsky, Little Rock, Arkansas: All I can say is that our individualized approach with the attending sometimes at tableside and scrubbed, and sometimes in the control area, particularly for diagnostic cases, works well for didactic and heuristic purposes. When communication is needed, it is performed discreetly over a microphone system. 

Is there a role for simulators?

John Hirshfeld, Philadelphia, Pennsylvania: I would like to know how effective my colleagues find simulators for teaching cardiac cath to be? Our institution has a “Sim Center”. In contrast to earlier sim models, I have used a new unit on an extended demo here. I found it to be a very useful device for teaching neophytes about coronary angiographic anatomy, because one could do a coronary arteriogram and change the radiologic projections to see how the arteriogram changed. I used this for our first-year fellows who have not yet rotated into the cath lab and, I believe, they found it to be a good introduction to coronary angiographic anatomy. They say that they found this to be helpful so that when they came into the lab and needed to interpret real coronaries, they came with a better knowledge of what they were looking at.

All of our fellows enjoyed playing with the simulator. However, I continue to harbor skepticism that there is a useful place for it in either a general or interventional cardiology training program. The basis of my reservation is that, while there has been considerable progress improving the sophistication of the simulation, the simulator does not yet satisfactorily replicate neither the actual technical challenges of interventional procedures nor the actual feel of the equipment manipulation. I am skeptical that practicing on the simulator enables one to gain a proficiency that would shorten the time and experience needed to achieve proficiency while doing real cases. I am inclined not invest in this unit. I realize that this may be somewhat swimming against the tide, as many constituencies are beating the drum for replacing actual procedure experience on patients with simulator time.

Gus Pichard, Washington, D.C.: We need to implement “technical skills training” with simulators. This is the future! There is no reason to subject a real patient to a trainee “trying to manipulate tools and achieve goals with catheters and devices” when the same can be achieved in a good simulator. For intervention, the new simulators can load the diagnostic film, and the trainee can experiment with the real anatomy. The trainees should come to the patient only after they had a chance to learn the basics with the simulator. The patient is getting additional radiation (without consent for it!), and the procedure is often prolonged, not to speak of possible less than optimal procedural results.

Bonnie Weiner, Worcester, Massachusetts: I agree, Gus. The issue is not the simulator technology anymore, but rather the right curriculum. The simulation should go beyond individual case practice and be a more comprehensive approach to technical skills and more than the “team training” or “patient management” that has been where most of the simulator systems are. There needs to be a graded, technical skills training course to develop the hand/eye coordination/understanding and muscle/nerve memory that build technical sophistication.

The bottom line

The patient deserves the best possible supervision and technical performance of the procedure. The attending is obligated to provide this by his presence, whether standing next to the trainee or in close proximity for those he deems are competent to provide the best level of care. The spectrum of opinion on the exact role of the attending varies, but common to all opinions is that the patient’s safety is our principle concern and supervision must ensure this. I also want to note that the teacher-learner relationship extends to the nurses and technologists in our labs, who in fact are the front-line teachers of the procedure as much or more than any attending. I hope this conversation will help you see the teaching of catheterization in a new light and prompt a review practices in your lab for best outcomes. n