key: cord-348458-dwj90mbq
authors: Narula, Nupoor; Singh, Harsimran S.
title: Cardiology Practice and Training Post-COVID-19: Achieving “Normalcy” After Disruption
date: 2020-06-22
journal: J Am Coll Cardiol
DOI: 10.1016/j.jacc.2020.06.036
sha: 
doc_id: 348458
cord_uid: dwj90mbq

nan

1 Achieving "Normalcy" After Disruption 2 3 4 Living through the COVID-19 pandemic has been the sentinel medical event in 5 most of our professional lives. In the hot spots across America, cardiologists and 6

trainees are deeply immersed working closely with physicians of all specialties as 7 COVID providers. Even in less affected locales, preparations have been made, 8 and the call to duty has been heard. There have been numerous recent 9

perspectives written by clinicians conveying their experience, emotions, and 10 advice on how to cope and care for the victims of this crisis. 1,2 As we hear 11

whispers of a "flattening disease prevalence curve" in New York City, and a hint 12 of optimism from the west coast thanks to early social distancing directives, we 13 are forced to confront the challenging question of what comes next. When we 14 reach the "end" of the COVID era, how will our lives have changed as practicing 15

cardiologists, fellows in training (FIT), and human beings in society at large? 16 17 18 The Practice of Cardiology

Disease Burden 21

It would be foolish to think that at the start of the next academic year 22

everything will return to the way it was. Epidemiologists, economists, and 23

politicians recognize that COVID-19 cases and their indirect effects will linger 24 well into the future. From an inpatient perspective, we are witnessing multi-organ 25 damage from COVID-19, including thrombotic sequelae, marked kidney injury, 26

and cardiac arrhythmias. As cardiologists, we should expect an influx of 27 outpatients who suffered cardiac complications from COVID or for whom 28 hospitalization unmasked conditions of hypertension, diabetes, coronary artery 29 disease, or cardiomyopathy. 3 Pent up demand from patients who avoided cardiac 30 care during the crisis will further contribute to outpatient volume. 31 32

Globally, there has been a marked decline in non-COVID medical disease 33

presenting to hospitals, such as myocardial infarctions (MI). 4 Theories abound on 34 whether the decrease in MI represents an actual reduction with at-risk individuals 35 abstaining from triggers or whether patients are avoiding the health care system 36 and infarcting at home. Recent reports of non-COVID mortality statistics from 37

New York of those who never make it to the hospital are alarming. 5 In COVID 38 patients, electrocardiographic abnormalities consistent with acute MI do not 39 always represent obstructive coronary disease. 6 As true ST-elevation MI volumes 40 resurge, discussions favoring fibrinolysis, recently resurrected to reduce 41 personnel exposure and due to delays in door-to-balloon time, should diminish, 42

to re-emphasize primary percutaneous coronary intervention (PCI) as the 43 standard of care. 7 

Processes of Reengagement 46 indications; however, this will not be tenable moving forward. The ACC 48

Interventional Council and SCAI differentiate elective cases from those in which 49 deferment may result in adverse clinical outcomes. 8 Postponing cardiac 50 resynchronization therapy in congestive heart failure or delaying a routine 51 echocardiogram in severe valvular disease can have profound repercussions on 52

individual health. The re-engagement of elective procedures will be highly 53 dependent on each hospital system, acknowledging the community's disease 54

burden and viral projections. However, the basic path to re-integration will 55

include: (1) availability of medical staff and the infrastructure to proceed with 56 elective interventions; (2) creation of "COVID-free" areas and implementation of 57

same-day discharge protocols as feasible; (3) categorization of procedures by 58 type; and (4) appraisal of cases by a designated subspecialty review board. 9 In 59 this setting, monitoring of iatrogenic COVID-19 cases as a function of total 60 volume will be integral.

Until vaccine development becomes a reality or herd immunity kicks in, we 63 expect ubiquitous use of PPE during all procedures and outpatient visits. 64

Proponents of "immunology passports" to document SARS-CoV-2 immunity 65 neglect the limitations of testing, uncertainties of immunology, and associated 66 ethical hazards. 10 When an effective COVID vaccination becomes available, we 67 expect there to be tax penalties for refusal and a quality metric for our patient 68 panels. COVID-status will additionally become integral to the standard history of 69 present illness. For protection of all parties involved, same day nasal swab 70

testing and documentation of antibody status should become standard for 71

patients undergoing any invasive cardiac procedure. In our clinical laboratories, 72

deep cleaning protocols must be enforced between cases despite delays in turn-73 around time and consequences to case volume.

Financial Burden 76

Hospital systems and private practices have suffered considerable 77 financial losses in prioritizing care for COVID-19 patients coupled with a 78 precipitous decline in elective procedures. The bipartisan CARES legislation has 79 allocated at least 50 billion dollars to support hospital systems and health care 80 providers 11 , and private physician offices and faculty practices are eligible to 81 apply for several loan-based programs, including the Paycheck Protection 82

Program and Emergency Economic Injury Disaster Loans. 12 Without the CARES 83

Act and future government intervention, many practices and hospitals will not 84 survive into the future.

Tele-Health 87

One of the silver linings of this human crisis has been cardiology 88 engagement with 21 st century technology. While the opportunity to perform video 89 visits has been present for over a decade, 13 it has taken a pandemic for 90 telemedicine to be nationally accepted. Centers for Medicare & Medicaid 91

Services has buttressed this effort by the development of toolkits to support 92 states in implementing tele-health for Medicaid and Children's Health Insurance 93

Program beneficiaries. 14 For the duration of the public health emergency, 94

Medicare will pay physicians for services provided during tele-medicine visits at 95 equivalent rates to office visits. 15 As its use persists post-crisis, expectations of 96

an optimal e-visit will evolve. Patients will obtain their own vitals using home 97

monitors. The transmission of modified EKGs through cell phone apps will be 98 standard. Patient-held tele-medicine stethoscopes could preserve auscultation as 99 integral to our cardiology identity. In many ways, telemedicine represents a 100 modern adaption of the home visits performed by our 20 th century 101 predecessors. 13 102 103 104

In the past months, FIT have learned skills in critical care, virology, and 107

palliative medicine as front-line providers. Yet, we must remain committed to core 108 cardiology education. Despite ACGME's leeway to cancel conferences in 109 pandemic emergency status, we have resisted this, deciding that maintaining 110 education provides stability in disruptive times. Video conferencing has been a 111 success, with widespread participation of fellows and faculty. While live lectures 112 will gradually return, video conferencing will persist in parallel with improved 113

HIPAA-compliant platforms and inter-institutional sharing. Virtual education is 114 being embraced at international levels. There were over 38,000 attendees 115

representing more than 135 countries at the virtual ACC/WCC Scientific 116

Sessions this year, validating the concept that online learning is far-reaching, and 117

inclusive for trainees who may not be able to participate due to financial or 118 logistical reasons. 119 120

Loss of rotations and cases has also imperiled fellows in many programs 121

to fall short of procedural requirements. For some, this will mean extension of 122 training pathways, but it will also force educators to reconsider how we teach. 123

Simulation training platforms can provide virtual repetition and pattern recognition 124

for procedures such as transthoracic or transesophageal echocardiography, 125 vascular access, and even structural heart interventions. The distinction between 126 procedural competency and procedure quantity has never been so important to 127

define. FIT themselves have become proponents of creative ways to enhance 128 patient care and education through multi-disciplinary care teams, tele-health 129 forums, and social media platforms for international idea exchange. 16 

There will certainly be adjustments made for onboarding new fellows this 132

July. It is also likely that the fall 2020 fellowship interview season will be 133 conducted virtually at most institutions. Replicating the in-person interview 134 experience in the digital space will be a formidable challenge. 

With many in self-isolation, the community-based impact of COVID-19 on 146 cardiovascular health will be important to monitor. Exercise programs via online 147 platforms have become pervasive, but will they be enough to counter inactivity 148 while at home? Home quarantine and closing of restaurants have left many to 149 cook for themselves, but will the health benefits of home cooking be mitigated by 150 the potential increased purchasing of "comfort foods" and preservative-laden 151 choices with long shelf lives? 17 The COVID-19 pandemic will leave a profound imprint on cardiologists, 160 trainees, and society for years to come (Figure) . We will have supported each 161

other to the best of our ability, understanding that the mental health sequelae for 162

health care professionals will be important to address. While none of us have 163 absolute foresight, we must learn from the harsh lessons faced and plan for 164 medical changes, including the deluge of cardiac care patients that will fill our 165 clinics, flexibility of FIT education to support cardiovascular training, and 166

continued integration of clinical science and technology.

Beyond medicine, some doubts linger. When will we feel comfortable 169 hugging a friend? In NYC, when will Madison Square Garden host its next 170 sporting event? Will our communities survive the economic devastation from 171 prolonged closure? If history has taught us anything, it is that humanity is 172 resilient. At our core, we are social beings, and in time, as we work to get past 173 this and the memories begin to fade, we will re-engage in the social embraces 174 crucial to our soul. But for some time, we must adapt to a "new normal." Let us 175 use this calamity to improve how we educate our trainees and enhance patient 176

care. From the ashes, our society will emerge more united than ever before, and 177

with a greater consciousness for public good. for cardiology practice and trainee education. 185

NYC Innocence Lost: Cardiology in the COVID-19 Pandemic. Circulation

The Isolation That Has Brought Us Together

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

Reduction in ST-Segment Elevation Cardiac Catheterization Laboratory Activations in the United States during COVID-19 Pandemic

ST-Segment Elevation in Patients with Covid-19 -A Case Series

Management of Acute Myocardial Infarction During the COVID-19 Pandemic

Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC's Interventional Council and SCAI

Triage Considerations for Patients Referred for Structural Heart Disease Intervention During the Coronavirus Disease 2019 (COVID-19) Pandemic: An ACC /SCAI Consensus Statement

Board on Health Care Services; Institute of Medicine. The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary

Adapting the Educational Environment for Cardiovascular Fellows-in-Training During the COVID-19

Nutritional recommendations for CoVID-19 quarantine

Post-COVID