December 22nd, 2011
A New Brave New World? Impact of Technology on Fellowship Training
John Ryan, MD
Last week, CardioMEMS failed to get approval from an FDA advisory panel for treating heart failure based on uncertainty regarding the benefit; the advisory panel also raised concerns about study bias. This intracardiac device measures pulmonary artery pressures that clinicians can use (in addition to other clinical signals, such as weight gain) to select therapies and decrease hospitalizations.
This announcement brought to my mind an issue separate from the decision and the reasons for it — the impact of technological advances on fellowship training.
As fellows, we almost all wish to be trained in the most novel techniques. Research and new discoveries are such an intrinsic part of cardiology that sometimes we might lose sight of the basics. And, a commanding knowledge of the basics and an understanding of hemodynamics, etc., are what drive most innovative thinking in the cardiology subspecialties.
We are taught in medicine to base decisions on clinical interactions with patients, rather than relying on technology to guide management. But is this how we practice or even how we should practice?
My attendings frequently impress me with their physical exam skills, but I am uncertain if their skills are better than mine because these physicians are 20 years my senior or because they did not train with the current electronic gadgets. Eric Topol of Scripps recently commented that he has not used a stethoscope in two years and instead favors a portable echo device. Similarly, many heart failure programs have incorporated computerized scoring systems to help predict readmissions and thus to decrease them.
Thus, my questions to fellows and more senior cardiologists:
- Has cardiology training lost some of its edge and intellectual nature because of the constant presence of advanced technologies, whether investigational like CardioMEMS or newly established like LVAD?
- Or do the information and clinical challenges provided by these advances sufficiently add to our training and our understanding of disease processes?
- How are fellowship programs and fellows incorporating these technologies into their training schemes? Does early adoption of the new technologies prepare or hinder fellows for real-world practice?
10 Responses to “A New Brave New World? Impact of Technology on Fellowship Training”
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Very interesting subject John. As you point out we have entered a new age of diagnostic and therapeutic interventions which rely on what appear to be complex technologies. Being an excellent clinician in previous times relied on becoming skilled at interpreting clinical signs; in the modern era we have to learn how to interpret a different type of information provided by differing technologies, and to be able to understand the implications of the information. Market forces are providing us with more and more tools, so it is harder to have the time to be as well trained and experienced as the clinican relying on the same clinical exam throughout his career. This is as much a challenge for senior cardiologists who act as mentors as for trainees, and its often the case that the trainee is just as up-to-date as the mentor by means of another modern technology- the digital era of education.
So fellows are being instructed from different directions, and it’s hard not to get swamped with information, which is a huge challenge to the trainee in modern times.
Great piece John! I agree that our skills, practices, etc have changed and will continue to change in the future. Technology is a great addition to improving the accuracy of diagnosis for our patients. I do not believe that there is anything wrong with this advance. I, however, would argue that the physical exam is an important part of the initial exam and follow up exams in clinic. It allows for a quick assessment for changes that may occur during the hospitalization (for example a new murmur after an MI) but should not be relied on solely as a holy grail that answers all of our questions. I believe that the technology will continue to improve and grow in importance during our training. Modalities such as MRI, echocardiogram, CT, etc will continue to improve and be validated for expanded use. Additionally, I believe that online teaching sources continue to improve allowing for concise postings of the latest information and trials.
As a clinician-educator I believe the strong challenge we face is not incorporation of technology into the training program but educating future cardiologists about their appropriate use. Fellows become familiar with each individual modality separately and are often given biased views of each modality’s superiority. Trainees sometime believe that the latest is the best. Good clinical skills are needed to be an intelligent user of technology-example is patients with chest pain with varying levels of risk.
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Thank you for your comments. You all bring up important points. I like your thought John about the trainee being just as “up-to-date” as the mentor. That is something I had not considered before. Incidentally my clinic attending bought me an electronic stethoscope for Christmas (thank you Dr A!) and I am excited to see how this hybrid technology will impact my skills. Eiman, you bring up an important point which is particularly relevant for clinicians in practise- let’s not forget that most heart failure patients are followed solely by PCPs without access to the armamentarium that we take for granted in academic training. And finally Indu, you bring up a critical point that is a tough part of fellowship, namely when on cath, the cath attendings typically feel that chest pain is definitively best evaluated with angiogram, which the nuclear doctors contend with. I think one of the great joys of training is getting ones own style and hoping that it is based on the best data as well as one’s comfort.
As an old non-cardiologist, a couple of comments:
-Taking the history will not change and will maintain its value, for many reasons
-You might not always have the technology you take for granted today, so do make the physical exam your routine
-New technology has taken a lot of the guesswork out of medicine and made us faster and safer
-New technology has to be tried out by academic centers, and if it really makes a difference, will find its way into our standard practice
-Digital technology is evolving at geometric speed and getting cheaper with every generation of products, this is something older generations of physicians have never seen or anticipated. You will look back at 2012 in a few years and say: “remember when…” So maintain an open mind and remember that you are, above all, a healer, no matter how the world goes.
When used appropriately, technological advances help supplement teaching, enhance learning, and most importantly, advance the care and safety of the patient. They do not, and will never supplant an open ear and thoughtful dialogue with the patient. Often times, the key to a challenging diagnostic dilemma lies in the history. Physical examination is the most cost-effective universal screening test to focus the problem. Fortunately, skills (and hence, diagnostic accuracy) improve with time and training. Depending on the pre-test probability, severity of the pathology, or the gravity of the treatment being considered then, further diagnostic testing can then be utilized. I agree with my mentors that not all-comers complaining of abdominal pain need a CT or an asymptomatic patient with a murmur an echo.
Having said that, the history and exam have their limitations. For instance, natriuretic peptide levels in the dyspneic patient on first encounter in the ED correctly identify HF better than any expert clinicians in less clear cut cases. The head CT differentiates hemorrhagic from ischemic strokes that the exam cannot. The echo differentiates systolic from preserved-EF heart failure, important in choosing treatment strategies. Ultrasound-guided central line placements improve procedural safety and decrease complication rates. VADs as destination therapy save lives and improve quality of life. Improved diagnostic accuracy, patient safety, and in some cases, improve chances of survival are some of the important contributions of technology to the of the care of the patient in this day and age. I sincerely believe that addition of technology to fellowship training with unbiased stewardship provided by mentors represent an advancement/enhancement in fellowship training.
Advances in technology are a must for the progress of medical science, and improving diagnostic & therapeutic skills, thus benefiting more and more patients.But, they should be used as guiding lights after a proper history taking & a thorough clinical examination,and not as crutches for support !!
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It is interesting that patients with chest pain presenting to the ED or to the PCP offices have at mostly a 20% chance to have coronary artery disease.
Complex technologies have failed to make a diagnosis in 80% of patients with chest pain.A large number of patients with undiagnosed chest pain have a poor quality of life.Thoracic Outlet Syndrome may be the etiological cause,checking the relative strength of the fifth finger on physical examination should be a must.See http://www.tos-syndrome.com
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