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Most training is sold on confidence. Show Me The Evidence is built on data.
In every episode we take a single study, clinical trial, or systematic review and work through what it found, how it was designed, and what it means for the way we teach and assess skill. We focus on metrics-based training and proficiency-based progression, the approach that asks learners to demonstrate measurable competence before moving on, and we trace its results across surgical, medical, and professional education.
This is a podcast for learning professionals and medical educators who want more than opinion. Expect plain-language breakdowns of the research, honest discussion of what the evidence does and does not support, and conversations with the people behind the studies.
If you make decisions about how people are trained, we think you deserve to see the evidence first.
My guest today is Professor
Serge Boveda.
Serge and I met a number of
years ago when we were
developing the metrics for a
cryoblation procedure.
Serge is co-headed department
in a Clinique Pasteur
He's principal investigator
for a European Commission grant on
the European Research Institute
& Simulation.
And more importantly, he's
president-elect
of the European Heart Rhythm
Association.
Serge, you're very welcome.
Thank you.
Hi, Tony.
You're a very experienced
electrophysiologist,
or an EP
So, what is an electrophysiologist?
Okay, that's a tricky question
to start.
An electrophysiologist,
as he says in
the name, is an electrician
of the heart.
You know the heart is a muscle
that plays the role of a pump
to bring blood everywhere
in the body.
For this muscle, you need blood
that is brought to the
muscle by coronary arteries and
you need also electricity
to make the contractions
of the muscle.
What is not working with the
electricity of the heart
makes the contractions too slow
or too fast and at maximum
it can be a hurt arrest if it's
too slow or even too fast.
And all the
pathology, the disturbances of
the heart rhythm, so the
rhythm of the heart, the beats
of the heart, is what an
electrophysiologist is
taking care of.
So we are treating the diseases
of the conduction system
that brings the electricity to the
muscle, so to the heart.
This is what is an electrophysiologist.
Do I make it clear?
You make it clear.
Okay, so what training did you go
through to get to this point
in your career?
I mean, I watch you training on
courses and I know you're
pretty good.
So what training did you do
to get to this point?
Okay, my training, to be
completely honest, this
is not finished.
I'm still training today, so I
think that it's a very
long venture.
My situation or the situation of
the electrophysiologist of
my generation is a little bit
special because we were
starting this specialty at
the beginning of the
interventional phase of
electrophysiology.
The operations started in the
90s, so end of the last century.
That was when I was a resident and
training at that time
was very scarce.
It was nearly no centres in Europe
or very few centres,
starting with an electrophysiology
program and it was very
difficult to get trained
at that time.
So I moved to a centre that had a
program of interventional
electrophysiology in Barcelona to
start training in 1993.
And during one full year, I learned
in the operation room
with the pioneers of operation
of this kind of operation
that were done, but at the
very beginning.
Then, obviously, it was
just the first years with this
specialty, we had to improve.
And this is why I say that the
training of my generation
was extremely long because we had
to learn new operations
that were even not existing when
we started this specialty.
So during the maybe 20 years
between the 90s and the
beginning of this century
until 2008, 2010,
new operations, new procedures
were invented and we had to train
all over these years without
stopping.
And training at that time, honestly,
was both very exciting
because we were learning nearly
every day, but it was
difficult because we had to be all
the time open to novel
procedures, novel strategies.
And yes, it was a very, very
interesting, very interesting
time.
Today, this has changed a lot.
So I
infer from that, that the practice
of electrophysiology has
changed considerably from when
you're a young resident.
So what would you say are
the major changes?
Okay,
I will just give you an example.
An operation of electrophysiology,
an ablation, for
example, ablation of some types
of arrhythmia that were a
little bit complex could last in
the 90s or I would say
even about 20 years ago, it
could last five hours.
Basically, the same operation
today is lasting maximum one
hour, sometimes less
than one hour.
So it has been a major change.
It's a completely fun work
for two reasons.
Basically, first, now training
is much more structured.
We have
much more accurate courses.
The theory has improved.
The way to teach also is much
more standardised today.
That's number one.
Number two, the tools and the
technology has changed a lot
and has improved the way of operating
and making the going
faster and even more
efficiently and safely
for the patients.
So I think that that's
very good news,
not only for the patient because
patient today is treated,
I believe, better than 20 years
ago, which makes sense.
We are improving hopefully.
But at the same time, for the new
generations, the new EPs
that are coming now, what we
call the young EPs,
it's much easier.
It's less exciting because
it's not something completely new.
But the good news is that I believe
that they are trained
in a much better way that I was
trained myself because
honestly, I had to train sometimes
alone because it was
difficult to find someone to
work with and to teach.
So today, it's not the case.
And that's very good news.
Today, we have fellows in most
of the European, big
European centres of
electrophysiology.
For example, in my centre, in
Clinique Pasteur Toulouse,
we have five fellows of
EPs every year
coming from all Europe,
even abroad.
And
these guys are staying one full
year, one full year in the lab.
They see in total
more than 2000 ablation, 2000
operation during one year,
when at my time, 20 years ago, the
biggest centre was doing
maybe 500 ablation in a year.
So now they see much more in a
better way, with better
tools, probably with better
proctors.
And
what for me,
I was learning in two years, today,
I think that they can
learn it in six months or maybe
one year maximum.
So yes, it has changed a lot.
It's a completely new world,
a new paradigm.
So I mean, that leads well into
my next question.
So how do you think training for
the EP, how has
that changed
your leadership
in training?
So
how has the training of
fellows changed?
Today's structure, we have a
diploma in France, for
example, it's a full specialty
that is a part of cardiology.
So there is a track where
the young
doctors go in order to learn
electrophysiology.
So it's a very structured
program with teaching courses,
and also
a special centers, so
expert centers where these students,
these fellows are
going in order to start
their training.
That's the first point.
The second point is that they we
have also new ways of teaching.
We have,
for example, simulators
that were not
existing at my time, when I
was a student myself.
And thanks to these new
tools, we can also
make a preparation of the
fellows before entering
into the lab.
So that's a very important phase
in which we can prepare
the young EPs, the young doctors
to go to the the procedure itself.
That's, I believe, a big plus.
But of course, and maybe we can
discuss about that, but
simulation doesn't make it all.
You need to
have simulation embedded into a
very structured program.
And that's maybe the core of the
question, the core of the problem.
And we have to be very careful.
So
you're the leader of the
European Commission funded
grant on
European Research Institute
and simulation.
Can you tell me a bit about what
that's, you know, what the
goal was the function of ERIS?
Yes.
Okay.
ERIS starts from a
philosophical idea that
that I had myself.
I wanted to
provide to propose something in
order to avoid to the young
doctors coming out and
wanting to do
this specialty to have and
to leave the same
problems and the same life that
I had myself for training.
So to improve the way of training,
ERIS, the European Research Institute
on simulation, is
based, as it brings in the
name, on simulation.
But not only on simulation.
Simulation is a part of the case.
It's only a tool that we're
using in the institute
in order to improve the
way of training
the young doctors, the young EPs.
Another idea about Eris, about
this institute, is that
we really believe that it's important
to have a platform
that is providing training for
the new technologies.
We are in a field, as I was
explaining before, that
electrophysiology basically has
started 30 years ago,
maximum, between 20, yes,
30 years ago.
So that means that every year
we're improving with new
tools, new platforms for new
operations, and this is
going very fast.
Even myself, every year, I have
to trade on novel
technologies, novel operations,
novel procedures, novel
strategies.
All this cannot be
assumed by a global university
program.
It's impossible to have a revision
of the program of a
university, of a medical school
every year, to
implement the novel technologies
and to change the program
every year.
Because you will have some technologies
that maybe will
last two, three years and then
will be improved and you
have to change again the program
all the time.
This is something that ERIS
will take care of.
ERIS will implement the novel technologies
when there is an
evolution, when one type of operation
is not used anymore.
We will skip it.
We will take the new one and
the idea is to be very
adaptive to this very fast way
of evolution in our specialty.
This is, I believe, a
very important
proposal in order to get all
the new generation trained to the
more accurate and more efficient
technologies that are
coming in the market every year.
I think that this is a little
bit the idea of ERIS.
So is simulation, is it a tool or
is it the magic bullet?
Oh
yes, of course.
Simulation is a tool.
Simulation is not, again,
simulation is not magic.
Simulation is not something that
will take a young doctor
and make it as an expert after
a couple of hours.
Simulation has to be used as
a tool, as I was saying
before, embedded in a structural
teaching program.
In these fields, the best
way to assess that
young fellows
are improving is to
measure all the
metrics that they are doing well
or not doing well.
The simulator is helping for that
because with a simulator,
you can mimic the operation
without
training directly on a
patient, which
today, in my opinion, is
not acceptable.
It's not acceptable to train
directly on a patient.
You have to start training
on a simulator.
And when a simulator is providing
to the teacher, to the
proctor, all the metrics that the
fellow did well, then
once everything is fine, the fellow
can go to the lab and
work with a proctor, again, not
alone, of course, but with
a proctor work in the real life
on a real patient.
No, I totally agree with
you, Serge.
One of the problems though
is I travel
around the world and teach
on courses.
I think some clinicians think
that simulation is a magic bullet.
I don't think that.
I think it's a tool for the
delivery of a metric-based
curriculum that's derived from
clinicians that are
experienced in the procedure and
preferably metric-based
curriculum.
That's one of the things that ERIS
does, which I think is quite good.
ERIS has been running for
about a year now.
What do you think are the major
lessons learned from the
application of a standardised
course using simulation?
Yes,
ERIS is still in the
learning phase.
We are, as you say, very, very
correctly, we are starting
by the beginning of this
year, 2026.
We provided, until now, seven
courses, in total seven
workshops on all novel
technologies.
And we took lessons from these
seven courses.
Things that worked well was the
interaction between the
fellows and the proctors that
was very, very positive.
The fact that the fellows
could train
in a proper environment on very
high quality simulators
besides faculties that
were very high.
And the fact that we could measure
the metrics was also a
very, very good experience and
very, very positive, I would say.
But we have to put more emphasis
on this part of assessing
all the fellows based
on the metrics.
What we are missing still today
for some kind of operations
are the very accurate metrics
that we need to
record.
We need to have all these metrics
in a very proper way.
And to base the evaluation
purely on that would
be a very good
point.
Another point that is
missing today is
the further evaluation
of the fellows.
Because these fellows, when they
are finished the course,
when the course has been delivered,
they have been
evaluated equitably, if I can say,
just after the course.
And that's good.
That's very good.
But then they are going back
to the hospital.
And what happens there?
What happens in the hospital?
Did they start working in the lab?
Did they start operating?
How much patients did
they operate?
Were there with a proctor?
Are they now in the phase that
they are a principal operator
or not?
What is the outcome of these
operations, et cetera, et cetera?
So all these parts, that
is the follow up,
is still not completely
done.
It's not completely clear.
And we have now put a lot
of effort on this.
This is not an easy way, but
this is a very interesting way.
Because I believe that here we
are setting the basis for
what I would say, the 2.0 education,
where we are now
basing education, not only
on the theory,
on the exams, but also
on the real life.
What happens next?
And this is a little bit the
journey that we want to
put in place.
Now, you're president-elect of
the European Heart Rhythm
Association, which is probably,
well, is one of the most important
professional scientific societies
globally for EPs.
In March, you published a paper
on digitally assisted learning in
cardiac electrophysiology
and cardiac implantable chronic
devices.
Can you summarise
the thrust of that
statement, what it said?
Yes.
I think that this document is very
important because, again,
it's putting
basis of the new way of educating
the EPs, the new
generations that are coming now
of electrophysiologists.
And that's what we wanted to do
in this document, is not
only to say what is working well
now and to explain what we
still need to continue, but also
to explain what is not
working really well and where
we should improve.
And clearly, there
is a lot of room for improvement
in training.
We need to use all the novel
technologies that are
provided today,
like I was saying, not only on the
simulators, but also on
virtual reality.
All the new ways of teaching that
are interesting, we
should embrace them and take
them into the training
programmes of tomorrow and
still of today.
I think that we have to start
today and to improve
during the next years to reach a
very high level quality
of education.
But not only that, technology
is only, as I was saying
before, a part of the problem, a
part of what we have to implement.
What we have to implement is also
the methodology and the
way that we are assessing the new
generation of electrophysiologists.
And in this way of assessing
what we are delivering and what
they are learning and what
they will use in the routine
practice, there is a very
important point that you know
very well, which is the
proficiency-based progression.
And this PBP should be completely
linked with this teaching
programme based on the simulator
in order to
learn with the fellows the way to
improve their skills in
the next month or even years
after the index training
programme.
I think that this is again a journey,
it's not a single day
effort, it's a daily effort during
months, during years and
sometimes during a complete life.
And PBP, it's a very interesting
methodology that makes it standardised
because again,
when you are treating a patient,
I believe that it's not
acceptable that a patient treated
by one doctor in one
hospital will be treated in a
different way than in other
hospitals, in other hands
with another doctor.
I believe that we have to standardise
the training, the
tools that we have today have
a very important
benefit.
I think that they have the possibility
of, let's say,
facilitate a big number, a great
number of operations
because they make them simple,
more simple, not completely
easy to do, but it's much
simpler than in the previous
years.
And we have to take profits
of these
novel technologies because
they can provide
better reproducibility for
the operations.
We have to take this opportunity
to implement also the way
that we are training the fellows
in order to provide also a
more standardised and a more
reproducible training for all
the young generations.
Because at the end of the day,
what we are looking for is
that all patients that will benefit
from an operation will
get the same chances of
success and the
same chances of not having
a complication.
And if we want to have this, if
we aim to reach this goal,
what we need is not only good tools
that are providing more
easy operations, but also good
training programmes that are
providing more reproducible learnings
and more reproducible
learning pathways for the students
in order to get a more
reproducible way of operating
patients.
I
diverge slightly.
At what point did you get that
when we were talking about
the or developing the metrics for
the cryoblation or did
you get that from conversations
in here?
What point did you get that?
Because you're spot on.
Because we are only you
and me, I can
tell you that you are a little
bit my guru.
I think that I got that.
I got that point when we discussed
together and you told me
about the way that you
were approaching
the not really teaching
but evaluation.
And I think that that was maybe
the missing link in my
mind, because I think that
personally I was prepared
to hear this talk.
I was prepared to hear these
words, but I didn't get
because this
is not my work.
This is what you see in a
lot of years now.
And when you explain me your methodology,
I said to myself,
this is what we are missing today
in order to get, as I was
explaining before, the goal
that we are aiming for
again, having the same chances
of success and the same
chances of avoiding complications
in all patients.
And this evaluation, these words,
these sentences that you
told me many years ago, because
it's not something that is
very recent, it's not coming
from yesterday.
But when we met the first
time and when
you made your point on
PBP and all the
journey that you did yourself
in this methodology,
I thought to myself, yes, this
is really interesting.
And we have to implement this
not only in the teaching
programs, but also probably in
the scientific documents.
And this is why today it's something
that is clearly part
and maybe at the core of the last
document we have made together
with ERIS last year for training.
Were you surprised how strongly
the document, the statement
about proficiency-based
progression, that
this is the direction we
have to travel?
Were you surprised?
I mean, I know you led it.
I was on the simulation
group,
but were you surprised that it was
so strong in terms of
what it stilled?
Because it certainly
sets ERA at the
forefront in the world of
where we should go.
Were you surprised?
I'm not surprised.
This is something that for
me, it's logical.
As a president-elect
of the European Heart
Rhythm Association, I want that
our association, that as
you stated rightly, is the most
important profession in
Europe and one of the leaders
in the world with the
Americans, obviously with the
Asians and with Latin America.
I think that we really want to
be the leaders on this.
We really want to be the most
advanced in the way of
preparing the new generations
because the future is
not us anymore.
I'm sorry to say Tony, you and me,
we are not the future,
but our responsibility is to
prepare the future and the
future is the next generation.
And we have to provide them a new
way of learning in order,
again, to improve the quality.
And that's for me not a surprise
to have the PBP,
Proficiency-Based Progressions,
inside the document.
We want to have it because
we believe
that this is probably the
best way to assess
the evolution and to assess the
training of the new generations.
So, yes, I'm very happy to have
this in this document.
And what we need now is
to explain and
is to implement in the training
programs,
first in Europe, of course, but
next in all over the world.
As a member of the, as one of
the co-authors and as a
member of the committee that
discussed simulation, I was
shocked of how forthright and how
accepting the members
were in terms of proficiency-based
progression.
And basically, they accepted
because
of the data that was already
available.
Unfortunately, that's not the
case in all scientific societies.
So,
is the Halsteadian training
paradigm dead?
No, it's not dead.
I think that's,
I am someone that,
as you know, because you know
me a little bit, I like history.
I believe that it's important
to take
base on what our predecessors
have made.
And they made it rightly because
at that time, at the
beginning of the last century,
Halstead, when he was proposing
this training program,
today, it's the way I was trained
myself, in fact, a few
years ago, more or less a few
years, but to be a resident,
the residency program, and the way
that you are completely
involved in this
world of the hospital, of the
operation room, with
proctors, with generations working
together, for me, it's
very positive.
And I think that the Halsteadian
training is not dead, but
we have to make it
modern.
We have to use now what we
have to improve it.
And even if we keep the same structure
with the residency
program, with the training centres,
experts working with
with young fellows in order
to transmit
knowledge, I think that
this is great.
But here we have to add what we
propose today with the
novel tools, the simulators, but
also the methodology that
is coming with these tools, because
these tools without the
method to use them are
not efficient.
They are not serving anything.
They are just like toys that you
are providing for people.
But this is not what we
are looking for.
What we are looking for is a tool
that is used properly,
and also that serves for
evaluating the fellows.
And this is something that we can
implement very well in the
current program.
This is what
we are trying to do with ERIS,
with the project of the EU,
the European Research Institute
on simulation.
Yes.
I mean, I totally agree with it.
I mean, people, they look to me
and they say, well, you've
just killed the Halstedian
training part.
I disagree with that.
I think the Halstedian training
paradigm has evolved.
And what ERIS is doing, what
we're doing, it just makes
the training more efficient
and effective.
And what we sent into the OR or
the cath lab is a pre-trained
novice.
They know how to do the procedure.
They've demonstrated they can do
it in simulation models,
but they still have to
demonstrate it
in the operating room
or the cath lab.
And so what we're doing is
we're shortening the
learning curve.
We're
making sure that the patient is
exposed to less risk from
the learning curve.
So should trainees during and
at the end of their
course, should they be assessed?
Of course, they should
be assessed.
Why?
Look, I take an example, a
very simple example.
I'm used to take this example.
I am working and living in Toulouse,
which is the city of
Airbus, planes, and nobody would
take a plane with a pilot
that has not been trained and
assessed properly.
So would it be fair to have a
doctor that is operating a
patient for the first time without
being training properly
and assessed in the right way?
No, it's not acceptable.
So, yes.
And again, yes, we have not only
to train our young
colleagues with the novel technologies,
with the novel
methodologies, but we have also
to assess them before they
are entering in the lab for
operating the patients.
This is for me mandatory.
And this is probably the basis
for the future of education
in this field.
Including medicine?
It has to be acceptable.
We are professionals, we are
dealing with patients.
This has to be accepted.
For me, I accept even
after 30 years
of experience, I accept
to be assessed.
I work with my colleagues, I
work with my fellows.
When I can improve something,
I will
improve it because this is
our responsibility.
We are operating patients.
Again, a pilot of a plane
that is not
landing properly has to change
his way of landing.
If we don't operate in
the right way,
we have to change our way
of operating.
Yes, of course.
Assessment is necessary.
I mean, I agree with you, but
you are the leadership.
And I'm not sure everybody
will agree with you.
But I totally agree with you and
I think it's the future.
The European Commission
recently has
implemented the idea that certain
professional groups
within medicine have to demonstrate,
or they have to do
courses, and they have
to demonstrate a
performance level to get
microcredentials.
Microcredentials, I think it's
a fabulous idea because
basically the microcredentials
are awarded from universities,
which means they have to be
legally accepted across countries.
Whereas today, if you do a course
in Spain or France,
they don't have to.
If they're awarded through the
universities, they have to
be legally accepted.
Do you think microcredentials
are a good idea or a bad idea?
No, look Tony,
it's the same microcredentials
are necessary.
The university is the house
of knowledge.
So the university is
the place where
we have to base our training
programs.
And the microcredentials
are the proof that these programs
are delivered in the
right way in the house
of knowledge.
And I believe that this is
mandatory and Europe will
improve a lot by spreading these
microcredentials because,
and this is again, you know, the
French were very in favor
of equality.
It's mandatory that the patient
that is treated in Spain,
in Italy, even in Ireland
should be treated in the same way.
I think that it's important that
the microcredentials are
delivering also the standard,
the proof that what is
delivered is delivered in
the proper way.
And with a
background, the support
of the university.
So yes, they are necessary and
they should be tomorrow, probably
at least this is what I hope, the
basis for the education
of the new generations, because
these microcredentials will
be again, the proof that all the
doctors in Europe are
trained in the same way and
in the proper way.
Yeah, no, I totally agree
with that.
Microcredentials are a fabulous
idea, but it has to have teeth.
We need proper standardised metrics,
validated metrics,
benchmarks to make sure that
the same standards are
delivered across the countries.
And that's one of the things that
the clinical trial within
the ERIS, I think that's one
of the most important
functions to demonstrate
unequivocally
that performance levels impact
on outcomes.
The device manufacturers are legally,
legally responsible
for instruction for use training.
Sure.
Published evidence suggests that
most clinicians on the use
of devices and so on,
they don't really know
the instruction for use.
Is that a problem?
It's a big problem.
It's a major problem.
And this is again why ERIS is
important and ERIS and all
these kinds of initiatives,
because
the training programs will be
based not only on PBP, will
be based not only on the
microcredentials, but they will
also be based on the IFU.
The instruction for use
have also to
be implemented in the teaching
programs.
And if you don't do
the operation or the simulation
phase and the training
program in the right way
with the IFUs,
you will not get the
microcredentials.
So that's a part of the
teaching program.
Yes, this is a major problem.
All the doctors should
use the IFUs.
But the company is legally
responsible for it.
So how should deliver
the training?
Should be the professional
societies or ERIS
Obviously we should be delivered,
but the companies or
the clinicians?
Who should be responsible?
That's a very, very important
point.
And I believe, and this is maybe
also a new way from the
Education 2.0, I would say,
a new way of thinking.
I believe, and most probably I'm
not the only one, that the
companies should be also involved
through the IFUs in the
teaching programs.
Of course, the teaching program
is the responsibility of
the university, is delivered
by the
professors, is prepared also
by the university.
But it shouldn't be done
with ignoring the companies
and the IFUs.
The responsibility of the companies
with the IFUs should be
taken in consideration
and even should
be implemented in the teaching
programs.
So
this is a way or so to say, in
a certain way, maybe the
diplomatic way, as you would say,
that we have to involve
in a certain point the companies
in the teaching process.
And this is, again, what as a university
we are responsible
for leading and to propose
in the next year.
I believe that until very recently
the university was also
working a little bit like artists,
ignoring some
other partners that are important
also in the teaching
journey.
And as you say, you're speaking
about the IFUs, and this is
a perfect example where we
should take this in
consideration and also having a
dialogue, a connection, a
discussion with the companies
in order to have these
implementing in the teaching
programs to speak with
the same voice.
Because if we are not saying the
same, then this is another
reason that the doctors are
not using IFUs.
And this is why we should have
a really very efficient
connection with the teaching departments
of the companies.
Because the companies, all the
companies, because they have
the IFUs, have teaching departments,
we should have a
connection with these people.
Yeah, I mean, I think there's
a competition there,
and maybe it's not that healthy,
that the device
manufacturers, obviously, legally,
they're obliged
to do the instruction for use, but
the fact of the matter
is the evidence shows that the
instruction for use as
delivered by them today
is ineffective.
And I think there needs to be a
conversation between the
scientific societies and the
manufacturers about the optimal
way to do this.
Because legally, I mean,
the clinicians, if they deviate
from the instruction for
use, they're not legally covered
by the indemnity of the hospital.
Okay, just
to finish up with
Serge, thank you.
Thank you for the conversation.
As always, it's been a delight
to talk to you and informative.
Thank you.
Thank you very much.
It was a pleasure, Tony,
like always.
Thank you very much.