Off Script: Monkey See, Monkey . . . Should Really Do, Before Being Set Loose

I was privileged to attend the excellent Trans-Septal Hands-On Training Program this morning.  A brainchild of the CRF Skirball Center for Innovation, this program was started a year ago to teach trans-septal access and was featured earlier this year at TVT 2017.  This year marks the debut of the program at TCT 2017 and is evidence of the continued interest in innovative education.  Trans-septal puncture represents relatively unfamiliar procedural territory for most practicing interventional cardiologists, but it is the gateway to a growing spectrum of interventional procedures from left atrial appendage occlusion to MitraClip.  Unlike many basic procedures, this step, if performed improperly, has a low complication threshold, resulting in cardiac perforation, tamponade, and death.  As procedural options proliferate and become more commonplace in the years to come, we may be faced with the significant challenge of training a large cohort of beginners as well as experienced interventionalists unfamiliar with the procedure.  How will we achieve this in an organized and consistent fashion?

Having trained fellows for several years, I have often been uncomfortable with the current model of interventional training adopted by most of us.  “See one, do one, teach one,” the apprenticeship model of training and stepwise mastery, all suffer from the same fundamental flaw when it comes to providing the best care for our patients.  Our trainee always has to start at zero somewhere.  We justify the need for exposing our patients to trainees by the need to train a new generation, but does it really have to start in the cath lab, on a real human?  None of our consent forms truly address this issue with our patients.  How many among us would, in full disclosure, consent to a PCI performed on ourselves or a loved one by a first-year fellow with 5 prior PCIs acting as first operator?  Despite the attestation of “I was present for the critical and key portions of the surgery and I was immediately available to provide assistance,” can we guarantee to be able to prevent all complications based on inexperience?

Despite the ubiquitous adoption and clear benefit of simulation by many professions such as with flight training, the current state of affairs of simulation in cardiac procedural training sadly remains in relative infancy.  Both the ACGME and COCATS, United States bodies that define cardiology education, mandate the use of simulation, but neither provides any guidance beyond this statement.  Research in the cardiovascular interventional field is sparse, with a handful of randomized studies.  Training curricula are poorly developed.  SCAI disbanded its simulation committee this year.  The metrics defining competency during training are unclear.  The costs of current platforms are prohibitive, with few training centers around the country.  Most of the current simulators in circulation are owned by industry, and opportunities for exposure are limited. 

On the brighter side, the old refrain of a lack of real-world fidelity from early users is being turned around by both Mentice and 3D Systems who are the two largest market leaders in the field.  The menu of cases available for simulation is expanding and increasing refinements are being made to ensure true-to-life fidelity and to include commonly encountered complications with response algorithms.  Both have features which allow for augmented reality representations with 3D anatomical visualizations, a feature which I have found greatly reduces training times.  Both feature the ability to include patient specific renderings and have even gone on to develop radiation exposure models to enhance awareness of the invisible specter of radiation we as a community contend with lifelong. 

We are currently at an important tipping point that will require clarity of resolve and a disciplined push.  To all the naysayers, simulation is essential if you work from first principles.  There are many obstacles to changing our paradigm of training for future generations of interventionalists.  Issues of cost can be resolved with increased adoption and the economies of scale.  Issues of how can be resolved through the continued development and validation of international curricula.  Issues of why I hope you agree are obvious.

Monkey see, monkey train on simulation, then monkey do.

This will hopefully be the standard, future foundation for competent cardiologists.