CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 3, September – October 2024 158 AFRICA offer solutions to a severe shortage of well-trained cardiologists in East Africa, the COVID-19 pandemic was shown in this study to result in a significant reduction in the total volume of patients in the cardiology service and, in turn, the number of training episodes, including both ambulatory and catheterisation laboratory (cathlab) cardiac procedures. There was an increase in didactic teaching sessions. Fellows felt that the pandemic has had an overall moderate to severe negative impact on their training. The interesting increase in ECG monitoring episodes may reflect an increase in anxietyrelated problems or an increase in uptake of certain procedures due to administration of potentially arrhythmogenic drugs such as hydroxychloroquine and azithromycin, which were considered appropriate in the early phase of the pandemic. In a similar survey in the New York metropolitan area, interventional cardiology fellows and their programme directors reported a significant impact on the fellows’ training owing to reduced volumes of procedures, conversion of cathlab units into in-patient COVID-19 units, as well as redeployment of fellows to care for COVID-19 patients. The authors concluded that the pandemic has had a severe impact on the fellowship training, and suggested tailored opportunities for remediation in order for the trainees to achieve their ultimate goals and meet end-of-training expectations.9 In line with this observation, published data from the USA and Spain indicated an overall reduction, in the range of 38 to 40%, in ST-elevation myocardial infarction (STEMI) activations across high-volume cardiac centres in both countries, compared to the numbers of STEMI activations before the COVID-19 era.10,11 Indeed, the reduction in patients and procedural volumes has been observed in other non-cardiac training programmes, including surgical and anaesthesia programmes across the globe and in Africa.12,13 Faculty and fellows from other African cardiology training programmes observed a similar decreasing trend in the training opportunities related to reduced volume. Many of these programmes have shifted to online and e-learning educational models in order to mitigate the challenges associated with the COVID-19 crisis.14 Although not a perfect measure of competence, procedural volume is used as a metric for the development of technical skills.15 We observed that many fellows had confidence that they would achieve the minimum required volumes for patient encounters and for certain procedures such as echo (TTE), Holter monitoring, treadmill testing and diagnostic coronary angiography by the end of their training, but were less confident about the development of more advanced skills in procedures such as PCI, device implantations and electrophysiology. In anticipation, some suggestions from the fellows included additional training time in the specific areas of interest, or continued supervision during early cardiology career practice or on-the-job proctorship. These approaches have been considered appropriate responses to training in resource-limited environments.16 The increase in the number of didactic tutorial events and access to virtual conferences during the crisis is likely to impact positively on their knowledge base. The increased and eased accessibility to international virtual meetings and conferences suggests that the increased availability of teachers may be a global phenomenon although the proliferation of webinar training may have been borne out of a global necessity. One observation was that most fellows had completed certain procedure volume targets such as transthoracic echo ahead of time in the programme. This was not expected by the trainers, but provided a cushion to allow focus in other areas. Systems that can adapt to allow fellows to shift their focus once competencies are achieved may be more adaptive than those that are rigid. The response of the population to the pandemic was dynamic and unpredictable as the situation evolved and government restrictions changed. Our study emphasises the benefits of an adaptive system. As far as fellowship training is concerned, there is still much unknown regarding the long-term impact of COVID-19, and it is not clear whether other cardiology training institutions in SSA should consider additional mentorship or training periods for their fellows. The current evaluation was conducted over only three months into the pandemic and a repeat assessment at a later stage may clarify the findings. The present study highlights the effects of the COVID-19 pandemic on cardiology training and indicates the need for proactive flexibility in fellowship training delivery. Some of these may include more emphasis on skills transfer that does not depend on human subjects, such as a clinical scenario and procedure simulators; angiographic and echocardiographic review sessions; as well as enhanced use of e-learning platforms. DeFilippis et al., while observing that the COVID19 pandemic resulted in a rapid transformation of medical education, emphasised that for fellowship training to be adaptive to the unprecedented changes brought by COVID19, programmes will have to include virtual education and the use of social media to maximise trainees’ experiences while maintaining their safety.16 Conclusion This article provides insight into some of the challenges surrounding clinical training and delivery of clinical care during a global pandemic. The findings showed that the COVID-19 crisis resulted in a significant reduction in the total volume of patients and cardiac procedures and, in turn, the number of training episodes. While interviewed fellows felt confident about acquiring the minimum requirements by the end of their training, they may not have achieved enough skills base in highly technical skills such as PCI. Opportunities for post-fellowship training in the form of continued mentorship and proctorship would be a valuable option for trainees in the case of further pandemics. References 1. Kumar P. Providing the providers – remedying Africa’s shortage of health care workers. N Engl J Med 2007; 356(25): 2564–2567. 2. Sliwa K, Zühlke L, Kleinloog R, Doubell A, Ebrahim I, Essop M, et al. Cardiology – cardiothoracic subspeciality training in South Africa: a position paper of the South Africa Heart Association. Cardiovasc J Afr 2016; 27(3): 188. 3. Aga Khan University Hospital. Aga Khan University Cardiology Training Curriculum. 2020 Oct 21 [cited 2020 Oct 21]; Available from: https://www.aku.edu/mcea/medicine/Pages/Cardiology-education.aspx
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