Interventional cardiology has seen a leap in innovations and is still progressing at a rapid pace, so cardiology training programs should adopt accordingly. The ability of mentors to advance knowledge and educate trainees determines the quality of care in our healthcare facilities. (1) In Iraq, the cardiology fellowship subspecialty program is a 3-year training program that can be started after completing four-year fellowship training in internal medicine. The main challenges in traditional cardiology training are how to give equal opportunities for all fellows-in-training (FITs) (especially in developing countries in view of limited resources) and how to meet the needs of cardiovascular care, particularly after establishing new cardiac centers across the country where the newly-educated cardiologists will work independently. Extending training to improve FITs competency can be very costly, especially in developing countries, with a huge impact on the healthcare system. (2) Therefore, changing the landscape of cardiology training became crucial considering the rapid expansion of this specialty.

In 2013, the European Society of Cardiology (ESC) adopted the new ESC Core Curriculum in general cardiology with more focus on concept of the Heart Team, patient-oriented training, non-invasive imaging, broader inclusion of cardio-oncology and new inclusion of acute cardiovascular care. (3) In 2015, the American College of Cardiology (ACC) issued the Core Cardiology Training Statement 4 (COCATS 4) that represented the latest ACC curriculum recommendations for fellowship programs, which included for the first time recommendations regarding critical care cardiology training and multimodality non-invasive cardiovascular imaging training. (4) Moreover, there are well-recognized fellowship training programs in preventive cardiology in US which can serve as role models regarding how to implement training in cardiology according to the unmet needs in this wide speciality. (5) Recent international cardiology fellowship programs are not only advancing curricular requirements, but also include certain approaches and specific scores to assess the progress of FITs’ competency and track their efficiency in training. (6) Such forward steps should motivate us to reconsider changing the training program landscape to fill the training gaps in recent programs.

In order to create a well-equipped generation of physicians, decisionmakers in the Council of Cardiology decided to pave the way for FITs by bridging the gaps in the traditional cardiology fellowship program. With this aim in mind, we sought to implement a new training model for cardiology fellows in training and assess their satisfaction level with this model.

Traditional cardiology fellowship programs focused primarily on training on diagnostic coronary angiography during the first year of fellowship and training on percutaneous coronary interventions during second- and third-year training. From October 2017 to September 2018, regular feedback was collected by trainers and mentors from adult cardiology FITs regarding their training. FITs highlighted gaps in device implantation, device programming and Holter basics, and electrophysiology study (EP) basics, in addition to reporting difficulties in real world practice in managing special populations like adults with congenital heart disease (ACHD) and pregnant patients with heart diseases; many of these skills were acquired haphazardly during training without equal opportunities given to all and with no proper well-organized training objectives.

Accordingly, a new training paradigm for the final (3^rd) year FITs was established by the Scientific Council of Cardiology from December 2018 to October 2019. This paradigm implemented five courses:

A rotatory schedule was assigned to include one fellow each month for each particular course. After completing training of all fellows, all FITs were surveyed for their satisfaction levels with the new program. We used a printed survey in PDF format which was sent by social media (Viber and WhatsApp) to all recruited FITs; the survey contained 11 sections with 28 questions focusing on their satisfaction level with each course, privileges and educational pitfalls of each course, as well as suggestions for future training programs for the next fellows to further improve competency.

Twelve final year FITs were engaged in the model; very high satisfaction was reported in EP and CMU training, while the lowest satisfaction level was reported with device implantation (see Figure 1). Starting part of this training program earlier, i.e. in the second year of the fellowship instead of the third year, was suggested by 33.3% of fellows. Heavy workload was reported by 83.3% of candidates mainly in device, EP, and CMU training. The main drawback of device training was the absence of hands-on training, which contradicted the course objectives despite the fact that FITs were trained for 5 days a week during the device implantation course. Duration of courses was requested to be longer for device training by 75% of FITs, while 50% of them felt that programming and CMU courses needed to be extended; 83.3% and 91.6% of candidates requested extending the duration of training in EP and ACHD courses, respectively. Future intensive training courses for cardiac imaging were proposed by 41.6% of FITs, while courses dedicated to transesophageal echocardiogram training were requested by 33.3%. Half of FITs felt they needed more familiarity with preoperative cardiovascular assessment and it was suggested to be included more extensively in future training curricula. FITs thought they were able to work independently (under no supervision) in primary PCI in 91.6% of responses, while only 41.6% believed they were capable of performing independent permanent pacemaker implantation, and 33.3% believed they could independently manage device troubleshooting. All fellows thought that this program bridged practice gaps, all of them believed that they were privileged for being recruited, and all of them stated the program should continue for future fellows in training.

Collaboration between all cardiac subspecialties and implementing this collaboration in educational programs can lead not only to improved interventional cardiology programs but can also plant the first seeds of other highly specialized cardiac services as has been done in other countries. (7, 8) Iraq is now heading towards filling practice gaps in the adult cardiology program along with starting highly specialized programs like an electrophysiology training program and peripheral vascular intervention fellowship program in order to provide highly demanding cardiac services nationwide.

Asking for continuous feedback from trainees and collaboration between mentors, trainers, and decisionmakers can help in addressing barriers that preclude standard training and bridging the gaps in traditional fellowship programs, which will contribute to preparing the workforce nucleus that can confront the challenges anticipated in improving cardiovascular care and practice with subsequent optimization of patient outcomes.