Author + information
- aService de Cardiologie, AP-HP Hôpital Cochin, Paris, France
- bFaculté de Médecine, Université Sorbonne Paris Cité, Paris, France
- ciLumens Simulation Department, Université Sorbonne Paris Cité, Paris, France
- ↵∗Reprint requests and correspondence:
Marie Hauguel-Moreau, AP-HP. Hôpital Cochin, Service de Cardiologie, Paris, France.
The aim of this paper is to present an innovative learning process for fellows-in-training in interventional cardiology, particularly for those who are managing pregnancies while pursuing their careers.
Although an increasing number of female physicians are pursuing a career in the field of invasive medicine, the number of women in interventional cardiology remains low: only 14% of American College of Cardiology fellows-in-training are women. This is in stark contrast with the trend in cardiology overall, where the percentage of female physicians has risen from 8% to 25% over the past 30 years. (1) One reason for this imbalance in the male to female ratio is the challenge of combining family and professional life with mandatory “on-call/duty” rotations in the cardiac catheterization laboratory. A young female interventional cardiologist sometimes has to juggle both starting a family and investing in training. The second reason is that radiation exposure during pregnancy could lead to fetal harm. In all, the decision is often hard to make: one can choose to start a family first and then undertake training in interventional cardiology, or vice versa. Most women consider delaying a pregnancy until after age 35 years for career reasons to be inadvisable because of a higher risk of chromosomal abnormalities in older mothers. This dilemma is illustrated by the fact that in the American College of Cardiology, only 63% of female cardiologists have children versus 88% of their male counterparts (p < 0.001) (2). This survey highlights that 30% of women had interrupted their training for more than a month, versus 13% of men, mostly because of pregnancy and childbirth. In a similar manner, 44% of the women had interrupted their training to reduce radiation exposure risk compared with 17% of men, and 50% of women planned a pregnancy during a time of nonradiation exposure compared with 15% of men (p < 0.0001) (2). Thus, these limitations could considerably reduce the motivation of a female cardiologist to pursue a career in interventional cardiology.
In France, interventional cardiology training consists of an 8-semester fellowship during which time is dedicated (1 year in all) to practical clinical aspects. A French trainee in interventional cardiology performs at least 100 cases of angiography and 50 angioplasties as second operator and at least 30 cases of angiography and 10 angioplasties as first operator. In addition, to validate the training and obtain an additional 2-year post-doctoral Academic Diploma (Diplôme Interuniversitaire de Cardiologie Interventionnelle), trainees have to pass a theoretical examination and defend a peer-reviewed dissertation. Therefore, managing pregnancy during interventional cardiology training is particularly difficult in France, mainly because a pregnant fellow cannot undertake intensive training, including exposure to x-rays.
I am a 31-year-old fellow-in-training (M.H.M) with 1 year of experience, including about 300 coronary angiograms (CAs) and 100 percutaneous coronary interventions (PCIs) as a second operator. My choice was to start a family first and then to train as an interventional cardiologist. However, early training is known to be crucial in the learning curve, and an interruption of >9 months during pregnancy has a negative effect on clinical skills. Furthermore, pregnancy can negatively affect a career, because other fellows continue to train and reach a level of autonomy earlier and thus benefit from better career opportunities. During the eighth month of pregnancy with my third child, I realized that my training and learning curve was suboptimal compared with colleagues who had not been pregnant. To continue my interventional training and stick to an optimal learning curve without radiation exposure during pregnancy, I was given the opportunity to undertake CA virtual educational training sessions. In my center, I was the first pregnant fellow in interventional cardiology to have followed a specific training program on a simulator.
I followed a program using an interventional cardiology simulator, Mentice G5 (Mentice AB, Gothenburg, Sweden), located in the iLumens Foundation (simulation laboratory, Université Paris Descartes, Paris, France), which offers the possibility of practicing on >400 cases in interventional laboratory cardiology and endovascular training. Under the supervision of experienced interventional cardiologists, I was able to perform 14 h of various interventional scenarios on the simulator for 1 week. I then had unrestricted access to the catheterization laboratory simulator for self-training. The simulation training program itself consists of:
• Coronary and left ventricle angiogram procedures;
• Virtual radiation management;
• PCI procedures; and
• Acute myocardial infarction and complications management.
The coronary module provides a range of cases with different patient anatomies and scenarios. For each case, challenging questions are discussed. All procedures start with a presentation of the patient’s file, after which we can perform a CA with a virtual scope using real wire and catheters. For PCIs and complicated cases, as well as real wires, we can use microcatheters and balloons (that simulate balloons and stents). The visual and tactile feedback (torque, resistance in heavy calcified vessels) is highly realistic and on the basis of experienced operators’ knowledge. The simulator is thus a way of considerably improving manipulation techniques with movement effects close to reality. In my case, I was able to perform 2 PCIs/week as a first operator shortly after my maternity leave, a rate similar to that of my colleagues who benefited from uninterrupted training.
Aside from allowing a fellow in interventional cardiology to continue her training during pregnancy, simulation training has several excellent teaching points. First, it allows the learner to acquire and practice techniques as often as necessary in relaxed and safe conditions at no cost. Second, case debriefing is less stressful because the cases are virtual. All mistakes can be discussed in detail during the debriefing, and trainees are encouraged to research the published data to find their own answers. Third, we can select and practice on cases as much as needed. However, a simulation-training program also has some limitations. A virtual case will never replace a real patient, and it is impossible to assess the operator’s ability to remain calm when faced with an emergency such as acute myocardial infarction in real conditions. Furthermore, puncturing the arterial access site is not yet possible with this simulator, whereas arterial complications, especially femoral artery puncture, constitute one of the most common vascular complications in CA with challenging radial approach procedures. This is a serious limitation of the simulator even if dedicated arterial puncture simulators do exist. Finally, access to the stimulator can be an issue, and I acknowledge that I had priority access due to my condition. On a more general note, virtual training focuses on safe practice, because procedures can be repeated and virtual radiation exposure and the volume of contrast medium can be compared.
The experience that I gained in CA simulation training due to my pregnancy has convinced me that such training, when combined with regular training, is an ideal way of improving procedure interpretation for fellows-in-training. The added value of simulation training is well known in surgical or other interventional fields such as laparoscopy, arthroscopy, and flexible endoscopy. Young surgeons use simulators to practice their technique before approaching real patients to gain skills and minimize potential complications. Although a simulator is an expensive investment, it can open access to training programs to a large population of fellows. CA simulator studies have shown reduced procedure time, reduced total contrast used, and reduced total fluoroscopy time in young interventional fellows (3,4). Simulation offers a consistent environment in which learning outcomes are primary and patient safety is respected. Although further studies are required to evaluate the clinical effect of virtual training in clinical practice, simulation sessions should be incorporated into a first-year cardiovascular fellowship curriculum as it is in other procedural specialties.
In conclusion, my simulator training was an invaluable experience for me, because I could keep practicing and learning in situations that, under normal circumstances, I would not have had access to due to my pregnancy. Furthermore, this experience reassured me that, through intensive and continuous training, I was able to reach the skill level of my colleagues who were not pregnant. Thus, promoting simulator training for fellows in interventional cardiology could be a way of balancing the male to female ratio in this specialty by making it easier for women to pursue their training without having to delay starting a family.
The authors thank Olivier Varenne, MD, PhD, for writing assistance.
RESPONSE: Can Simulation Decrease the Sex Gap in Interventional Cardiology?
Dr. Hauguel-Moreau should be commended for sharing her experience with pregnancy and interventional cardiology training, given the paucity of available information and the frequent lack of pregnancy-related mentorship. The use of a simulator to reduce the effect of pregnancy on a trainee’s ability to advance her skills without radiation exposure is quite resourceful. Furthermore, this may help in maintaining skills during and after maternity leave, as well as from other medical conditions such as orthopedic considerations, which preclude working in the catheterization laboratory for a period of time.
In the simulator experience described by Dr. Hauguel-Moreau, she felt that using the Mentice G5 simulator was realistic. However, she noted some limitations of the system, including a lack of vascular access simulation. Simulation has been slower to evolve as a component of cardiology training than in other surgical fields; nonetheless, it is now advancing rapidly. This will likely become an integral component of all cardiology and interventional training programs in the future. The advances of high-fidelity simulation in interventional cardiology will not only help to mitigate the effect of pregnancy or illness on training, but will also lead to greater consistency of training and greater patient safety by having trainees learn initial lessons far from patients. Given the benefit from the use of simulators in surgery training seen in randomized trials (1) and the reduction in procedural risk with increased operator experience, as simulators evolve, their role will clearly expand and will help to increase women’s career options and family choices.
The growth of women in interventional cardiology continues to lag behind the growth of women in medicine, cardiology, and even other surgical fields. The causes for this lag have been investigated, and include the perception of the career’s effect on family life and radiation exposure. Women typically have little education on the occupational exposure risk during pregnancy, and as such, are challenged in making an informed decision. In the United States, the Pregnancy Discrimination Act protects women from employment discrimination on the basis of pregnancy (2). Therefore, women are allowed to continue as interventional cardiologists or trainees despite pregnancy. Appropriate monitoring using a radiation badge under the lead at waist level, monitored monthly, is important for ensuring minimal fetal exposure during pregnancy. Using all available techniques to reduce radiation during cases (shielding, minimizing angles, careful collimation, and additional lead for the operator) is an important strategy that should be maximized for the pregnant physician. In the United States, pregnancy occupational exposure to radiation is a choice and should be maintained as a choice. This is not true for all countries, where by law some countries prohibit occupational radiation exposure during pregnancy and even during the breastfeeding period. Thus, the use of simulators for training may be of even greater benefit for female interventional cardiology trainees when training with radiation is prohibited.
Simulators always have had a promise to advance clinical skills, provide consistency for fellowship training, and increase patient safety. Moreover, they may have a unique role to decrease the sex gap in interventional cardiology.
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- for the Society for Cardiovascular Angiography & Interventions' Women in Innovations (WIN) group (2011)
- American College of Cardiology Foundation