Left-handed Cardiology Trainees Face Unique Challenges

Fran Lowry

January 11, 2021

Left-handed cardiology trainees face unique challenges when it comes to learning how to perform common procedures, according to a new report.

About 10% of the world's population is left-handed, and rates of left-handedness among medical students and practicing physicians is believed to be similar.

Prashant Patel

"Extrapolating this to 3,017 active general cardiovascular fellowship positions and 339 interventional cardiology fellowship positions for the year 2018 to 2019, it is estimated there are more than 300 LH [left-handed] trainees in US cardiovascular fellowship programs at any given time. Despite this, any standard clinical setting is designed to be convenient for RH [right-handed] providers, thereby creating a variable amount of impediment for LH trainees," write Prashant Patel, MD, and Mandira Patel, DO, from University of California Riverside School of Medicine, California.

"With about 10% prevalence, left-handedness is far more common, including among cardiology trainees, than most people realize. Most of the procedural set up is designed for the right-hand majority, and it may cause a variable amount of impediment for the left-handed trainees. It is very important for the academic cardiology community to recognize this," Prashant Patel told theheart.org | Medscape Cardiology.

The findings are published in the January 5 issue of the Journal of the American College of Cardiology.

Patel, who is left-handed, said he was prompted to look into the issue because of his own experience.

"In my first procedural rotation several years ago, I noticed that I was positioning myself somewhat differently than my attendings due to my preference for using my left hand for fine motor control," he said. "I started looking up existing literature to see what other left-handed cardiologists have done in the past, but realized that nothing along this line was published."

"I started discussions with my colleagues and superiors and found that our small cardiology fellowship program contains about 20% to 40% of left-handed trainees at any given time, and we felt it was important to elaborate on this," he added.

Practice makes perfect, and repeated practice eventually leads to automation of motor procedures, but the learning curve may be more protracted for left-handed trainees. "Acquisition of procedural skills is a function of time and repetition. Eventually, most practicing left-handed cardiologists see that as a nonissue and do not even realize they may have gone through a differential learning curve based on their hand dominance," Patel noted.

"South paw" cardiology trainees face their first challenge in the examination room.

Physicians typically examine patients from the right-hand side of the bed. The majority of clinic offices are set up for the right-handed provider, with the examining table placed with the head of the bed distal from the door and the left side of the bed aligned in close proximity to the wall, leaving examination on the right side of the patient as the only option. In the hospital setting, monitors and intravenous poles are usually placed on the patient's left-hand side of the bed.

"This practice, more than anything else, is born out of tradition. The same clinical examination can potentially be performed with the same accuracy and efficacy from the left-hand side," said Patel.

In the echocardiography lab, some facilities perform transthoracic echocardiography from the right side of the patient, thereby requiring the operator to get the right scanning hand over and across the patient.

"This is ergonomically disadvantageous, as one has to sit on the table, reach over the patient, and twist the torso. Scanning from the left side of the patient is ergonomically superior in preventing back injuries and may be advantageous for the left-handed person as the probe is held in the dominant hand," noted Patel.

In the cath lab, the difficulty for left-handed cardiologists starts with establishing arterial or venous access.

"The two most frequently used arterial access sites are right radial and right femoral. Both of them pose unique challenges in terms of positioning for most left-handed trainees in the early part of their training. The right arm is kept adducted and externally rotated in a standard setup, which is difficult to access for a left-handed operator, and would require the operator to use their nondominant right hand awkwardly to gain access," he said.

A solution could be to reposition the patient's arm using a radial board into abduction of the arm at about 45 degrees, with external rotation.

"This creates room for the left-handed operator to stand caudal to the patient's arm and approach the radial access site conveniently using their dominant hand," Patel suggested.

For the femoral approach, the left-handed operator could stand left of the patient and either get left femoral access or reach out across to the right groin of the patient and obtain access in this manner, or alternatively, the operator could resort to using their right hand to gain right femoral access.

"The large size of the femoral vessels allows even the strongly left-handed operators to get accustomed to using their nondominant hand with practice. This may be preferable to switching to the left side," he said.

There are also some advantages to being left-handed, Patel said.

This is true "especially in the cath lab, for example, establishing antegrade right femoral access for peripheral interventions," he noted. "Having a left-handed operator can also come in handy when two operators need to simultaneously and quickly work on both groins, as is often the case in complex coronary or structural interventions. Left-handed operators are also at ease obtaining left radial access, which has been shown to have certain advantages over right radial access," he said.

"We hope to raise awareness among the academic cardiology community about left-handedness," Patel added. "We hope that acknowledgement, support, and minor modifications in work flow will allow a lot of young trainees in the early part of their career to stay on course and realize their full potential in this procedural specialty."

An Insightful Paper

"This paper by Dr Prashant Patel and Dr Mandira Patel is most insightful about the unique challenges and occasional opportunities for the left-handed cardiologist," writes Simon Kendall, MB BS, President, Society for Cardiothoracic Surgery Great Britain and Ireland, London, in an accompanying response.

"As a left-handed cardiac surgeon, I am embarrassed not to have considered such significant issues for my cardiology colleagues: the edict of examining a patient from the right side, performing echocardiography with the right hand, and the complex arena of catheter laboratory that is designed around the right-handed majority. Before reading this paper, I had not appreciated that for my whole career I have had to use my less-favored right hand when inserting a balloon pump," Kendall writes.

"Drs Patel and Patel have written very sensible conclusions, such as that left-handedness should be acknowledged and adapted for and the training environment has to help access the specific tips and tricks from others, as shared in cardiac surgery, for instance. They rightly describe this as not a binary phenomenon and that there is a spectrum of laterality, so that some left-handers will adapt with ease and others will need more time and patience to learn the necessary skills," he writes.

"We are fortunate to live in an era of increasing awareness and tolerance. Left-handedness is one small example of such progress."

Patel and Kendall report no relevant financial relationships.

J Am Coll Cardiol. 2021;77:97-101. Full text, Response

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