As in all graduate medical education, focus on general cardiology training is shifting away from number of procedures and moving towards clinical competency. For common procedures such as coronary angiography and trans-esophageal echocardiography, fellows have ample opportunity to practice in a structured, supervised learning environment. However, some procedures remain infrequent and fellow exposure is based on the “luck of the draw.” It can be difficult for training programs to ensure equal and adequate exposure for all fellows.  

In an informal poll of program directors from varying program sizes, locations and types, pericardiocentesis and transvenous temporary pacemaker wires were the top two identified infrequent procedures. The average graduating fellow at these programs has exposure to 2 – 4 of these procedures each. It is crucial to keep in mind that the importance of experience and competency in these procedures depends on an individual fellow’s career plans.  

How can programs provide adequate training for these low-frequency, high-stakes procedures?  Strategies include:

1. High-fidelity simulation models.
Pro: Allows repetition of procedural steps, leading to a systematic approach that can be recalled during clinical emergencies. 
Con: Expensive, often used less than 10 days per year and tactile elements may not adequately mimic real life.

2. Low-fidelity simulation models such as the gelatin model for pericardiocentesis.
Pro: Inexpensive, reasonable tactile mimicry of true pericardiocentesis.
Con: Does not re-create the intensity and high-stakes nature of the clinical environment.

3. On-call pager: In a manner similar to STEMI call, this can be utilized for infrequent procedures and allow fellows the opportunity to participate even when not on the primary service caring for the patient.  
Pro: Increases the potential for exposure to infrequent procedures.
Con: Still relies upon “luck of the draw” and may result in multiple fellows present for the procedure.

4. Practice in non-emergent settings: Temporary pacemaker wires, in particular, are frequently inserted during electrophysiology procedures or transcatheter aortic valve replacement procedures, and general fellows can be assigned to perform this non-emergent portion of the procedure even when on other rotations.  
Pro: Increases potential for exposure to infrequent procedures and occurs in a non-emergent setting.
Con: May pull general fellows away from other assigned clinical duties.

This article was authored by Lorrel E. Brown, MD, FACC, assistant professor of medicine, Division of Cardiology, at the University of Louisville in Louisville, KY.