Defining COCATS Level "Zero"

July 20, 2016 | Sudarshan Balla, MBBS

I have distinct memories associated with the date July 1. It was on this date that I started my cardiovascular fellowship and three years later became faculty at the University of Missouri. It is a good time to reflect on the past and seek areas of improvement to make a difference for future Fellows in Training (FITs).

My first rotation during fellowship was in the cath lab. A flurry of thoughts ran through my mind every day after I received my schedule. I had no clue of the workflow in the cath lab. It would not be an exaggeration to say I felt unnerved. When I first entered the lab, I was met by my savior, the senior fellow who explained the process of informed consent, introduced me to the staff, demonstrated draping the patient and "zeroing" the lines. It was an excellent start to the rotation. On my first call, I received a call from a patient with an implantable cardiac device that he had received a shock from his device. He lived three hours away from the hospital. I couldn't decide if I had to tell him to come to the emergency room or call my electrophysiology (EP) attending for advice.

It is common for FITs to encounter such situations from day one of their fellowship. The transition from an internal medicine resident to a cardiology fellow has a steep learning curve. Clinical cardiology, invasive angiography, echocardiography, multimodality imaging and EP are vast subjects on their own and the trainees' fund of knowledge is variable. It would be logical to lay a foundation across modalities for all trainees entering fellowship.

One approach is to run a boot camp for FITs during orientation. The boot camp is a place for FITs to meet and greet when they start their fellowship, breaking the ice. The objective is to educate incoming fellows about the basics of procedural and non-procedural aspects of cardiology fellowship, defining a Core Cardiovascular Training Statement (COCATS) level "zero."

The curriculum would include didactics and live workshops. Didactics would be 15 minute lectures by faculty and senior FITs on common cardiovascular problems, imaging and arrhythmias to name a few. Some cardiovascular fellowship programs in the U.S. have a setup like this but some do not. A dedicated boot camp with a significant involvement from existing fellows can work both ways. The senior fellow takes the role of a teacher when giving didactics. The incoming fellows, upon understanding the approach, can hit the ground running. Workshops could be conducted on performing transthoracic echo, cardiac device interrogation and hemodynamics. Use of a simulation center to practice arterial access, central venous access, pericardiocentesis and endotracheal intubation enhances procedural skills.

The concept of a boot camp can lead to camaraderie, fulfill the role of fellows as teachers, increase fellow satisfaction and above all improve patient care. Defining the boot camp as COCATS level zero can lead to widespread adoption at the national level – something training directors should consider in developing fellowship curriculum and incoming fellows should look for when choosing their fellowship location.

This article was authored by Sudarshan Balla, MBBS, assistant professor of clinical medicine at the University of Missouri.