Comprehensive training for the future pediatric cardiologist.

India faces a huge burden of pediatric and adult congenital heart diseases (CHDs). Many acquired valvar, myocardial, and vascular diseases also need treatment in childhood and adolescence. The emergence of pediatric cardiology as an independent specialty has been a relatively recent development. A few centers of excellence in pediatric cardiology have developed. However, the requirement of pediatric cardiac care and pediatric cardiologists is far in excess of what is available. There are no guidelines at present in India for uniform training in pediatric cardiology. Many training programs are nonstructured and do not focus on the regional needs. Both core training and advanced training programs are essential to provide adequate numbers of community-level pediatric cardiologists and academic leaders respectively. This article proposes a detailed plan and curriculum for comprehensive training of future pediatric cardiologists in India.

INTRODUCTION

Pediatric cardiology is a relatively young discipline in India. The last three decades have however, seen a spectacular growth of the specialty. Many centers have developed the capability to correct congenital heart disease (CHD) in early infancy. The initial generation of pediatric cardiologists mainly comprised adult cardiologists who took special interest in CHD. Learning pediatric cardiology was largely self-motivated in the earlier years. The National Board of Examinations (NBE) started a 2-year fellowship in 2001, and about 125 pediatricians have qualified to date. A few institutions have established themselves as centers of excellence, with impressive volumes and high standards. Why then, do we need a road map in India for training in pediatric cardiology?

A closer look at the present scenario reveals major inadequacies despite small pockets of high achievement. A huge gap exists between India's requirements for pediatric cardiologists and the available numbers.[1] It is generally recommended that one infant and newborn heart surgery program is required for 5-10 million people.[2] This would translate into a requirement of at least 1,000 pediatric heart centers for all of India. Only about 32 centers and 130 trained pediatric cardiologists are available. An estimated 72,000-100,000 children suffering from CHD needing intervention are born every year in India.[13] The burden of rheumatic fever and pediatric valvular heart disease remains significant.[4] There are large parts of the country with no pediatric cardiac services.[56] Training programs are often nonstructured, nonfocused, and not specific for the local needs. Factors such as the expected burden of patients, regional requirements, placements, and the trainee's career are not taken into account in planning training programs. Inadequate exposure to basic clinical, pathological, and hemodynamic teaching, and a disproportionate emphasis on invasive–interventional cardiology are common drawbacks in many training programs. Planned research, long-term follow-up, and multicenter data sharing are lacking in Indian pediatric cardiology.[7]

Training in pediatric cardiology consists of core training and advanced training. The former enables the doctor to acquire the knowledge and practical skills to provide quality health care to children with cardiovascular disease in the community, outpatient clinic, or in the hospital. Advanced specialty training in one or more selected areas imparts the knowledge and expertise necessary to develop into a leader in the field. The purpose of this article is to propose a comprehensive road map for core training in pediatric cardiology. The author hopes that it will initiate an open discussion among all stakeholders. Eventually, the debate can evolve by a consensus into the guidelines for training. The proposed framework will cover the following areas:

Attributes of an ideal pediatric cardiology training program.

Trainee requirements and selection.

Goals and levels of training.

Approach to pediatric cardiology training.

Core training in pediatric cardiology.

Allied specialty training.

Pediatric cardiology in the community.

Clinical research and teaching.

Advanced subspecialty training.

Proficiency assessment and exit examination.

Career guidance and follow-up.

Attributes of an ideal pediatric cardiology training program

ATTRIBUTES OF AN IDEAL PEDIATRIC CARDIOLOGY TRAINING PROGRAM [FIGURE 1]

Ideally, the center for pediatric cardiology training should be part of a multispecialty pediatric hospital or cardiovascular hospital with adequate infrastructure. Essential facilities for a cardiovascular unit include outpatient and inpatient service, electrocardiography, radiography, echocardiography, cardiac catheterization, angiography, interventional procedures, intensive care unit, and laboratory services. Some of the following facilities are desirable: Computerized tomography (CT), cardiac magnetic resonance imaging (CMR), stress-testing, ambulatory electrocardiogram (ECG) monitoring, head-tilt testing, pacemaker follow-up, radionuclide imaging, and pulmonary function testing. With a uniform training program and collaboration among training centers in India, the fellow can be rotated to other centers to cover all areas. A comprehensive library facility is a must. An optimum balance between the number of trainees, trainers, and volume ensures good training. Going by the rule of thumb, the requirement per trainee can be considered as follows: 2 teachers, 200 echocardiography studies/year, 100 catheterization procedures/year, and 100 pediatric cardiac operations/year. An essential requirement is an ideal environment for safe patient care and for learning to go on side by side. A committed faculty must provide supervised skill acquisition with gradual progression to self-sufficiency and independence.

TRAINEE REQUIREMENTS AND SELECTION

The ideal trainee would have a good foundation in pediatric health care. Although previous training in pediatrics would be preferred, the entry qualifications could be any one of the following: MD (pediatrics/medicine), DNB (pediatrics/cardiology), DM (cardiology), or an equivalent degree in an allied clinical discipline. At present, selection is based on marks scored in an entrance test. Two additional criteria can also be considered:

Interest and aptitude for pediatric cardiology as judged by previous projects, past training, research experience, or voluntary service and,

Faculty interview with the shortlisted candidates to find the best match for that particular center.

It is strongly recommended that the future mentor be part of the selection process.

GOALS AND LEVELS OF TRAINING

The primary goal of training in pediatric cardiology is to acquire the knowledge and practical skills to evaluate, diagnose, and manage cardiovascular diseases in young patients. The goals also include academic skills of presentation, teaching, literature review, and research. The training must impart the interest and ability to continuously educate oneself throughout one's career, and to make academic contributions to the specialty.

The duration and content of the training program will depend on the targeted level of competence and career goals. Three levels of training and competence can be considered:

Level I training (duration of 1 year) will provide basic training in different areas of pediatric cardiology before going on to the next level. Level 1 training will also be adequate for pediatricians, intensivists, adult cardiologists, and other specialists who intend to participate in pediatric cardiac care.

Level II training (duration of 2 years) will be required for all trainees intending to practice as the primary consultant for pediatric cardiac diagnosis and treatment, and for procedures such as diagnostic cardiac catheterization and simple interventional procedures.

Level III training (optional) will provide advanced subspecialty training in specific areas such as adult CHDs, interventional pediatric cardiology, pediatric electrophysiology, advanced cardiac imaging, fetal cardiology, heart failure, heart transplantation, and circulatory support.

This article will mainly focus on a 3-year training road map, which will provide Levels I and II proficiency training for future pediatric cardiologists. Interested cardiologists may opt to train to Level III in one or more subspecialty areas after successful completion of Level I and Level II training.

APPROACH TO PEDIATRIC CARDIOLOGY TRAINING

In the recently published 2015 SPCTPD/ACC/AAP/AHA revision for training guidelines for pediatric cardiology fellowship programs, there has been a paradigm shift toward competency-based training.[8] Earlier, the emphasis was on the time spent in training or the numbers seen/performed. The current approach is to give emphasis to competency in each area while fulfilling the prescribed minimum period of training and performing the minimum numbers. Competency would be evaluated by the training program directors and by other examiners, which would be the basis for either certifying completion of training or for recommending further training. This concept should be adopted in training programs in India. Thus, a trainee would have to undergo the prescribed period of training, along with continuous objective evaluation and documentation of clinical competence in each field before being considered eligible to take the exit examination. The training should cover the following domains in each field:

Knowledge of theory

Knowledge of theory includes anatomy, pathophysiology, etiological basis, epidemiology, clinical presentations, natural history, diagnostic methods, treatment modalities, follow-up care, and preventive aspects. Standard textbooks, review articles, monographs, and original articles are excellent sources of medical knowledge. Methods of imparting knowledge should be a combination of didactic lectures, group discussions, topic reviews, case reviews, demonstration, and simulations.

Practical skills

Practical skills in patient care include clever history-taking and examination, workup, diagnosis, and initiating appropriate treatment. Activities that help to improve practical skills are bedside discussions, demonstrations, practice sessions, protocols, data interpretation, and constant review of the changing clinical situation.

Management and communication skills

All available data must be used to formulate a scientific and cost-effective management plan for the patient's disease. Proper coordination of different caregivers such as pediatricians, surgeons, anesthetists, other medical specialists, and paramedical staff is essential. Effective communication with the patient and family is necessary. The information provided to the patient must be simple, factual, and unambiguous. Skills in management and communication are best imparted by example in real-life practice. The fellows must be able to observe and work with the faculty members in all areas.

Evidence-based treatment and recent advances

All treatment should be based upon sound scientific principles. The fellow must, at all times, be encouraged to make choices of treatment based on available evidence. The choice of treatment and the supporting reasons must be documented clearly. Regular journal reviews and update sessions are essential to keep abreast of new developments.

Quality and philosophy of pediatric cardiology practice

The success of a pediatric cardiology training program lies in ensuring development of the trainee into a mature well-rounded specialist who, apart from being knowledgeable and skilled, has also imbibed the philosophy of humane, appropriate, and ethical practices. Regular case reviews, critical self-analysis, medical audits, feedback study, adverse events analysis, and mortality meetings should all be part of the routine work schedule.

CORE TRAINING IN PEDIATRIC CARDIOLOGY

Core training provides the foundation for the future pediatric cardiologist, and includes the following fields: Clinical pediatric cardiology, echocardiography, pediatric intensive cardiac care, cardiac catheterization, allied specialties, and clinical research. The suggested schedule for core training in pediatric cardiology is depicted in Table 1.

Table 1

Proposed schedule of 3-year training in pediatric cardiology

Clinical pediatric cardiology

Adequate training in clinical pediatric cardiology is critical to provide a solid platform for more advanced development. A total duration of 9 months of training is recommended, split into three periods of 3 months each in the 3 years. In the initial period, the trainee should refine his/her skills in evaluation and workup of the patient. Rapid identification of the immediate medical issues that need attention such as severe hypoxia, hypercyanotic spell, or respiratory distress is important. The aim should be to quickly relieve the symptoms and prevent deterioration. The trainee must learn to summarize the patient's problem and his/her assessment in a concise but clear manner to the consultant. This is an art that needs to be developed and practiced throughout the training period. In every case, the fellow must document his/her impression and proposed plan, and then observe the faculty member's management. Often, what is ideal may be different from what is practical and appropriate, keeping in mind the location, facilities available, the patient's background, economic status, intelligence, and other factors. Every investigation and report is a subject for study, especially if it involves imaging, hemodynamic data, or pathology material. The fellow should present the case on faculty rounds, grand rounds, and joint cardiac surgical meetings. The idea is to understand, analyze, and present a cohesive story rather than to simply read out the reports. All relevant information should finally be included by the fellow in the medical summary. The faculty has tremendous responsibility as well as opportunity in the development of the above-mentioned skills. The department's philosophy and work culture will also have a major impact on the fellow's progress toward clinical competence.

Echocardiography

Echocardiography has become an indispensable tool for pediatric cardiologists. The recommended duration of training is 3 months each in the first and second years, with a minimum of 200 echocardiography studies in each year. While this training aims to provide basic abilities, practice and refinement of the method and interpretation will continue throughout the fellowship and beyond. The initial part includes understanding the principles of echocardiography and Doppler, safe sedation, monitoring, echocardiography views, recording of good images, measurement of chamber dimensions, and anatomical description of common pediatric heart diseases. The fellow must correlate the clinical picture with the echocardiography findings, and attempt to quantify abnormal flow, regurgitation, obstruction, and shunts. General skills in the echocardiography laboratory include basic understanding of the machine and transducers, care of the equipment, teamwork, time management, documentation, and confidentiality. The trainee must also participate in bedside echocardiography, targeted echocardiography in the emergency room, and in screening studies at schools and camps. In the later period of training, the candidate should become familiar with contrast echocardiography, transesophageal echocardiography, intraoperative echocardiography, tissue Doppler echocardiography, three-dimensional echocardiography, and fetal echocardiography. The senior echocardiographers and faculty are responsible for providing guidance, training, and supervision. The training requirement of the fellow has to be balanced with the patient's comfort and well-being. Discussion must be a continuous activity with each member of the team helping and teaching the junior colleague.

Pediatric intensive cardiac care

Rotation through the pediatric intensive cardiac care unit (PICU) is recommended for 2 months in the first and second years respectively. PICU training is intended to develop proficiency in the management of acute cardiac problems, care of the operated cardiac patient, and provide cardiac care consultations to other specialties. The supervisor is usually the intensivist or pediatric cardiologist in charge of PICU. The fellow must learn to use protocols and checklists in the management. An effficient triage of patients, quick grasp of the immediate issues, rapid response, leadership in a dynamic clinical situation, and smart resource management are other abilities, which need to be developed. Clear documentation and proper handover practices are important in the PICU. The PICU provides opportunities to become skilled in obtaining vascular access, hemodynamic monitoring, respiratory management, ventilation strategies, fluid and electrolyte treatment, nutritional management, and cardiopulmonary resuscitation. The clinical pharmacology of cardiovascular medications is of great relevance in the PICU. A regular multidisciplinary round in the PICU improves the ability of the fellow to interact and coordinate with other specialists.

Cardiac catheterization

Three levels of training in cardiac catheterization (CC) can be defined. Level I training provides an understanding of the principles of hemodynamic studies, indications and contraindications, mechanism of oxygen transport, oximetry studies, and cardiac angiography. It will enable the trainee to make referrals for cardiac catheterization, interpret catheterization reports and angiograms, and reach appropriate conclusions for management. Level II training is necessary to develop competency in performing diagnostic CC and some basic interventions. Fellows in pediatric cardiology must complete both these levels of training (total duration of 9 months) in the 3-year program. Level III training (additional period of 12-24 months) is necessary for pediatric cardiologists intending to practice as interventional specialists. Some of the Level III skills can be acquired by elective rotation or focused training for a shorter period. The latter would be applicable to previously trained people who want to obtain expertise in specific areas. A minimum of 100 patients would be desirable at each level of training, with a good mix of congenital and acquired heart lesions in different age groups. CC in teaching units must be performed in a systematic, comprehensive, and technically correct manner. At the same time, the fellow needs to know how the invasive study can be used to complement noninvasive tests and imaging. Paying attention to and discussing the individual steps in the CC procedure are important. The trainee should keep a log of all procedures including all relevant details.

In the initial phase of CC laboratory posting, the fellow must become familiar with the equipment, physics and hazards of radiation, protection measures, pressure-recording methods, basic angiographic principles, contrast media, infection control, sedation practices, and cardiorespiratory monitoring. At the end of Level I training, the fellow should be an efficient assistant to the primary operator. Knowledge of normal and abnormal hemodynamic values, pressure waveforms, cardiac output, and resistance calculations will enable the fellow to start interpreting the findings under supervision. Catheter manipulation in the patient requires repeated practice to access desired areas in the circulation without causing injury. In the next phase of CC training, the fellow should strive to become a safe operator capable of performing diagnostic catheterization and angiography. Postprocedure monitoring until full recovery, adequate documentation and treatment of complications (if any), discussion with the patient/family about the results, and charting the future course of treatment are other important aspects of the training.

It is strongly advisable for all teaching units to hold regular joint meetings of cardiologists and cardiothoracic surgeons where the fellow should present the patient's data. Such “heart team” meetings help to ensure that all aspects are considered and the most optimal strategy is selected for a successful outcome.[9] The findings at operation and the cardiac surgeon's feedback are important resources for understanding and correlating the patient's medical condition. Apart from procedural and diagnostic skills, the CC laboratory is an excellent ground for acquiring general management and quality assurance training. Finally, Level II CC training should include some basic interventional procedures such as balloon atrial septostomy, balloon pulmonary valvotomy, pericardial drainage, and temporary cardiac pacing. Acquiring knowledge about the hardware, indications, limitations, and possible complications is essential.

Adult cardiology

Adult congenital heart disease (ACHD) is an important subspecialty in India because of a large number of untreated and operated adults with CHD. Three months’ training in ACHD and adult cardiology is recommended in the third year of training. A clear understanding of the pathophysiology of all common ACHD is necessary, especially focusing on the natural history, possible events, and their impact on the person's life. ACHD often causes multisystem dysfunction. This calls for multidisciplinary consultation, interaction, and coordination. The trainee must also understand the effect of noncardiac diseases, social issues, job-related matters, marital concerns, insurance problems, and financial difficulties on the course and outcome of ACHD. Observation in the adult cardiology rounds and coronary care unit will give an insight into coronary artery disease, hypertension, and diabetes mellitus. The fellow must attend adult angiography sessions, as many ACHD patients need coronary angiography for congenital anomalies and coronary artery disease. Familiarity with the hardware and methods used in adult CC is often useful in pediatric cardiology practice.

ALLIED SPECIALTIES

The future pediatric cardiologist needs a reasonably good knowledge of other specialties. General pediatric training should have provided exposure to many aspects including nutrition, infections, neonatal health, infant health, epidemiology, growth, development and socioeconomic issues. Cardiac pathology, cardiovascular surgery, and cardiac radiology are the other closely related allied specialties. The training program must include rotation of 1 month in each specialty.

Cardiac pathology

Studying cardiac pathology specimens is useful in understanding the anatomy and pathophysiology of heart diseases. A study of the cardiac embryology and development will enhance understanding of the disease and its consequences. The faculty should utilize museum specimens, surgical specimens, models, atlases, and computer-based material to teach. Some programs may consider cardiac pathology training as optional for pediatric cardiologists.

Cardiac radiology

Cardiac imaging by CT and CMR is a rapidly growing subspecialty in pediatric cardiology. The trainee should learn the principles, methods, interpretation, and limitations for the optimum utilization of these two techniques.

Cardiovascular surgery

Partnership with the cardiac surgical team is an important component of success in any pediatric cardiology service. Joint meetings with cardiac surgeons, discussion of clinical and catheterization data, choice of intervention, and review of operative findings are of great educational value. The cardiology trainee must develop proficiency in intraoperative imaging by epicardial or transesophageal echocardiography. Surgical posting is also a great time to do data collection and analysis on the late outcome of some CHD.

PEDIATRIC CARDIOLOGY IN THE COMMUNITY

It is easy for a trainee in a tertiary-care pediatric cardiology center to get carried away by technology and the exotic variety of diseases. It is therefore, important for every pediatric cardiology trainee to work in the community to get a proper perspective of the problem. A 2-month posting is recommended in the third year but the experience should be carried through one's entire career. A medical college hospital, district hospital, or a general pediatric hospital with a mixed patient population would be an appropriate setting. Participation in health camps and home visits should be encouraged to observe the impact of heart disease in the context of other pediatric health issues. Follow-up and rehabilitation programs for operated CHD in the community offer excellent opportunities for studying the natural history and the functional recovery. More and more patients with operated CHD and chronic cardiac failure are on long-term palliative treatment. Domiciliary pediatric cardiac care is not available in India at present. The fellow's training program offers an opportunity for centers to initiate and develop this activity. A logbook must be meticulously maintained, recording all activities done in this period. A detailed report should be prepared by the trainee at the end of the posting. A research paper or a project in the community is another excellent method of showing competence.

CLINICAL RESEARCH AND TEACHING

Clinical research is a vital component of the training program. It provides an in-depth understanding of the topic, and experience in collection, analysis, and presentation of data. At least one planned research project should be completed during the training. The fellow must also be encouraged to present, discuss, and have write-ups of unusual clinical cases, presentations, or outcomes. Audits and review of results must be encouraged. The trainee must have regular interaction with the quality assurance department and the managers.

Teaching and learning are intricately related and extremely important during training. Teaching the juniors is perhaps the best way of understanding the subject and clarifying one's thoughts. Each person in the department should teach people around him/her at every possible opportunity. This can include nurses, technicians, physician assistants, junior doctors, physiotherapists, and anybody else involved in the patient's care. A comprehensive program and an appropriate environment for mutual teaching are essential.

ADVANCED SUBSPECIALTY TRAINING

Many fields in pediatric cardiology have progressed to highly specialized levels. Advanced subspecialty training in selected centers is recommended for pediatric cardiologists who desire to achieve Level III proficiency in specific areas such as ACHD, interventional pediatric cardiology, pediatric electrophysiology, advanced cardiac imaging, fetal cardiology, heart failure, heart transplantation, and mechanical circulatory support. Fellowships offering subspecialty training for 1-2 years are available both in India and abroad. A detailed discussion of the curriculum for such training is beyond the scope of this article. More commonly, shorter and focused training is sought by practicing cardiologists to achieve a specific skill or proficiency in one particular procedure. Some examples include device closure of septal defects, stenting of large arteries, pacemaker implantation and programming, follow-up of transplant patients, and many others. The training will have to be individualized for the duration (1–6 months) and the content.

PROFICIENCY ASSESSMENT AND EXIT EXAMINATION

Evaluation for competency should be a continuous process in the course of daily work and in all areas of clinical care. Observation during work, clinical rounds, progress notes, discharge summaries, response to emergencies, problem-solving capability, communication, and feedbacks are all useful in the evaluation. In addition, the director of the training program in consultation with other teaching staff should make a regular schedule of evaluation and documentation in each area. The process can include periodic quizzes, written tests, problem simulations, mock drills, case studies, literature searches, writing assignments, and other methods. The evaluation should be objective and based on clearly defined competency goals. Group discussions, meetings, journal clubs, teaching sessions, workshops, and conferences provide additional opportunities to know the trainee's depth of understanding and practical capability. The trainee should maintain a log of all activities including particulars of patients and procedures. The log and the evaluation should be shared and discussed with the trainee. Constructive criticism, suggestions for improvement, and recommendations for additional training in certain areas are important.

Exit examinations by external faculty have the advantage of unbiased evaluations and important feedback for the training program itself. It should however, be noted that exit examinations cannot replace satisfactory completion of training and internal proficiency assessment. In fact, the director of training has to be satisfied with the completeness of training before he/she certifies the candidate to be eligible for the exit examination. A team of two external examiners and one or two internal examiners typically conduct exit examinations. The examination should be comprehensive and cover all aspects of pediatric cardiology. The focus should be on practical and clinically applicable knowledge, rather than on rare and exotic topics. Awareness of one's limitations and the ability to mobilize additional resources for help are also important, and must be tested in the examination.

CAREER GUIDANCE AND FOLLOW-UP

Career guidance and development of the future consultant are important extensions of the mentor's responsibility. Two factors should be taken into consideration:

The individual's strengths and interest, and

The requirement, job availability, and the future prospect in that community.

Adequate research, advice, and appropriate help are necessary to kick-start the fellow on the path of professional growth. A long-term association between the faculty and the young cardiologist must be developed for continued discussions, sharing of ideas, and retraining in specific areas, if necessary. The growing cardiologist must also be encouraged to develop a multidisciplinary network of people, today's key to personal and professional advancement.

Financial support and sponsorship

Nil.

Conflicts of interest

No disclosures of any kind.