A Roadmap to Skills Mastery in the Cath Lab

One of the many essential things we seek to learn in the cath lab is technical skill mastery. During my cardiology fellowship at McGill University in Montréal and my first year in interventional cardiology fellowship at the University of Calgary, I had the privilege to be trained by the best operators and teachers. I’ve learned that there is no fast and dirty process for procedural skill development, but there are critical fundamentals needed in order to escalate the learning process. These are the intelligent and efficient building blocks involved in acquiring the ideal skill sets needed for simple and complex catheter-based cardiovascular interventions. 

There are 10 paramount fundamentals to developing life-long skills in the cath lab. If you’ve recently started interventional cardiology fellowship, engrave these in your mind:

1.     Commit to providing high-quality patient care and performing excellent procedural technique like a craftsman. It is a life-long process, and there are no shortcuts. Skill is continuously refined by practice, and learning to master many new cognitive and motor skills is essential to perform the procedures safely and efficiently.

2.     Thrive on cognitive skill development and sound judgment, not only technicalities. Know your procedure, but most importantly know your patient. Remember to make sure the planned procedure is indicated and develop risk accounting skills—weighing alternatives, passing sound judgments, and making decisions—for optimal patient care. 

3.     Make yourself uncomfortable every day. Struggling through challenging procedures is a critical part of the skill-development process of troubleshooting difficult technical obstacles. Be adaptable and creative when dealing with problems. Remember, only that which challenges you changes you.

4.     After each procedure, ask yourself how you could have done better. What worked? What didn’t? And why? Be brutally critical about your technical skills. If you get in the habit of doing this every time, you will not only be conditioned to better take constructive criticism from your peers and superiors but you will also position yourself to become a better operator.

5.     Push yourself to acquire the skill of 3-D mental visualization rather than pattern recognition when looking at fluoroscopic images. Acquiring this skill is paramount in structural heart interventions. Deep understanding and integration of cardiac anatomy and imaging (such as TEE, cardiac CT, and fluoroscopy) will make you a better operator.

6.     Avoid relying on luck when performing a technical procedure. While we all have unexpected success in the cath lab from time to time, taking the time to advance your cognitive and motor skills will only benefit you in the long run. Celebrate all of your successes, but focus mostly on the ones you feel confident you could readily repeat. 

7.     Strategize and anticipate complications like a chess player. Always think a few steps ahead and have a plan. Visualize the procedure in your sleep. Break it into chunks, study each step, and ask yourself what might go wrong. What is your bailout strategy? Are you prepared technically? With time, this approach will prepare you and enhance your crisis and emergency management skills for unanticipated events.

8.     Simplification is key. You will hear this many times in the cath lab. There is no need to make things more complicated than necessary. Always remember to simplify your technical steps as much as possible without compromising quality or safety. 

9.     Hang around with the right mentors. Seek a mentor who communicates and verbalizes in a concrete and specific manner. This person will be vital in your learning of technical maneuvers, so it’s important that they can efficiently teach you. Having a mentor who can assess your cognitive, technical, and reasoning skills will promote your progress toward independence. Always accept their brutally honest criticism, and know it comes from a teacher who cares to make you better.

10.  Become a learning machine. Educate yourself frequently. Attend conferences. Meet and learn from industry engineers. Take your fellow colleagues to lunch and learn from them by sharing interesting and challenging cases. In a dynamic field like interventional cardiology, systems and processes can change monthly, and you stand to benefit from being the first to know about the latest device, pharmaceutical, or regulatory news. 

This article is dedicated to the memory of Dr. Luc Bilodeau. He was a superb operator, teacher, and innovator and will be missed by the interventional cardiology community.