ACC/AHA/AAP RECOMMENDATIONS FOR TRAINING IN PEDIATRIC CARDIOLOGY

Abstract

Steering Committee: Thomas P. Graham, Jr, MD, FACC, FAHA, FAAP, Chair; Robert H. Beekman III, MD, FACC, FAHA, FAAP, Co-Chair; Michael D. Freed, MD, FACC, FAHA, FAAP; John W. Hirshfeld, Jr, MD, FACC, FAHA; Thomas Kulik, MD; John D. Kugler, MD, FACC, FAAP**AHA CVDY representative††AAP representative; Tim C. McQuinn, MD, FAAP; David J. Sahn, MD, MACC, FAAP; Victoria L. Vetter, MD, FACC, FAHA; and William B. Moskowitz, MD, FACC, FAAP†Task Force Members: Mark A. Creager, MD, FACC, FAHA, Chair; John W. Hirshfeld, Jr, MD, FACC, FAHA; Beverly H. Lorell, MD, FACC, FAHA‡‡Former task force member during writing effort.; Geno Merli, MD, FACP; George P. Rodgers, MD, FACC; John D. Rutherford, MB, ChB, FACC, FAHA; Cynthia M. Tracy, MD, FACC, FAHA; and Howard H. Weitz, MD, FACC, FACPTraining Guidelines for Pediatric Cardiology Fellowship ProgramsThomas P. Graham, Jr, MD, FACC, FAHA, FAAP, Chair; and Robert H. Beekman, III, MD, FACC, FAHA, FAAP, Co-ChairPediatric cardiology is a complex, multifaceted specialty composed of diverse clinical and academic subspecialty areas. It is characterized by rapid growth of subspecialty areas and swift incorporation of new information from the clinical and laboratory sciences. It is important, therefore, to define the fellowship training required to launch a successful career in pediatric cardiology. The following document represents the first broad-based effort to do so.In 2000, the Society of Pediatric Cardiology Training Program Directors (SPCTPD) embarked on the process of defining fellowship training guidelines. The process itself was broad-based and inclusive. All pediatric cardiology training program directors were invited to nominate members to participate in the training guidelines task forces; in turn, each task force was comprised of all nominated members who agreed to participate. Therefore, all training programs were provided an opportunity to actively participate.In 2002, the American College of Cardiology (ACC) approved and published the Revised Recommendations in Adult Cardiovascular Medicine Core Cardiology Training.1 As the SPCTPD was concluding its training guideline development, plans were formalized to use a similar process through the ACC Pediatric Cardiology/Congenital Heart Disease Committee and the ACC Training Program Directors Committee. Accordingly, a steering committee was developed with original authors of the Pediatric Cardiology Training Guidelines to form a liaison with the ACC, the American Heart Association (AHA), and the Section on Pediatric Cardiology and Cardiac Surgery of the American Academy of Pediatrics (AAP) to agree on the final guidelines and to publish them widely.These guidelines are written with the planned goal of serving as a practical resource for directors of pediatric cardiology training programs. We also hope that this document will prove useful to the Residency Review Committee (RRC) for pediatric training programs in the revision of requirements for the accreditation of pediatric cardiology programs. The general requirements, clinical competencies, and oversight for fellows in pediatric cardiology would remain the same as outlined by the Accreditation Council for Graduate Medical Education (ACGME).The guidelines proposed in this document address overall recommendations for training in pediatric cardiology and important subspecialties within the field of pediatric cardiology. Although we understand that the pediatric RRC sets minimum standards for accreditation of fellowship programs, this document endeavors to define a more comprehensive set of guidelines for pediatric cardiology fellowship training. Fellowship training guidelines are presented for: general pediatric cardiology (including inpatient care and consultations); echocardiography and noninvasive imaging; electrophysiology; cardiac catheterization and intervention; cardiac intensive care; adult congenital heart disease; and research participation. Each section other than general pediatric cardiology specifies “core” and “advanced” training experiences. Core recommendations are intended to be common training experiences for all pediatric cardiology trainees regardless of long-term career goals. Advanced recommendations are additional training experiences for trainees intending to develop a clinical or academic area of special competence. All guidelines are recommended experiences, and not absolute mandates, as it is recognized that each training program has unique strengths and that clinical and academic variation across training programs provides important diversity for the specialty.Table 1 summarizes the approximate time commitment (in months) recommended for core training in the task force reports that follow. Variations in these time commitments should be allowed, as pediatric cardiology programs vary widely in size, organization, and emphasis. For example, in some programs, fellows may get considerable cardiac intensive care unit training during their general inpatient experiences and not require a two- to four-month stand-alone rotation. Thus, the training guidelines must provide programs with flexibility to address individual trainee clinical and/or research training needs during a core fellowship of 36 months’ duration.The training program must possess the faculty expertise, patient volume, and inpatient/outpatient facilities to provide meaningful trainee experiences as outlined in this document. All faculty should be board certified or possess suitable equivalent qualifications. Recommendations for trainee and faculty evaluation are those outlined in the “general and special requirements” as published by the ACGME, and training should take place within a program that is accredited by the ACGME.A comment about trainee research participation is appropriate. The field of pediatric cardiology is absolutely dependent upon research (basic and clinical) for meaningful progress. There is a critical need for the development of physician-scientists in our specialty to assure such future progress. Therefore, it is key that training programs begin to prepare trainees for a successful investigative career. Such preliminary research training will in most instances require 18 months or more. The balancing of clinical and research training will continue to be a major issue for training programs. It is highly probable that trainees who want to pursue a physician-scientist career will require at least four years of fellowship to begin the academic process and to finish training in the clinical areas. The authors are in complete agreement with the newly published American Board of Pediatrics (ABP) Training Requirements for subspecialty certification concerning scholarly activity, meaningful accomplishments in research, scholarship oversight, and differing pathways to train physician-scientists.The authors of this section declare they have no relationships with industry pertinent to this topic.The goals of pediatric cardiology training include acquiring the cognitive and procedural expertise required to provide high-quality care to children with cardiovascular disease, acquiring the academic skills to make meaningful scholarly contributions to the specialty, and, importantly, to develop the capacity for ongoing self-education beyond the years of formal training.The general training of pediatric cardiology fellows builds on the general clinical and academic skills acquired during residency training. The pediatric cardiology fellow should be given broad exposure to clinical activities in pediatric cardiology inpatient and outpatient care, pediatric cardiology inpatient and outpatient consultations, and in preventive cardiology. The academic skills of formal presentation, small-group teaching, literature review, data analysis, and study design are also components of the general training guidelines.A fundamental goal of clinical training is to acquire bedside diagnostic skill and the ability to provide high-qualilty consultative inpatient and outpatient pediatric cardiology care. The core skills of history-taking and physical examination are the only means for correctly initiating diagnostic and management options appropriate to the individual patient, and these must be heavily stressed at all points of patient contact. Pediatric cardiology fellows should be observed by faculty while performing key portions of the history and physical examination, and to also have the opportunity to observe faculty perform history-taking and physical examination, so that meaningful discussion of useful strategies and techniques may develop. Consultation services, general inpatient wards, and outpatient clinics all provide excellent opportunities for such interaction.The pediatric cardiology fellow must have the opportunity to provide not only inpatient and outpatient consultation services but also direct patient care in both inpatient and outpatient settings. There must be a continuity of care in the outpatient clinic so that fellows can begin to appreciate the course of pediatric cardiac disease over time and its cumulative impact on individual patients and their families. The combined time commitment of the general inpatient and inpatient consultation services should be no less than three months. The continuity outpatient clinic should begin early in fellowship and continue throughout training, preferably on a biweekly basis. Both inpatient and outpatient experiences should include exposure to the management of the adult patient with congenital heart disease.There are many ways for general inpatient and outpatient practices to be organized. In the delivery of high-level inpatient and outpatient care the pediatric cardiologist must demonstrate effective team leadership, accurate and efficient medical record keeping, sensitivity to medical ethical issues, an ability to communicate with and support patients and their families through stressful decisions and experiences, and show strict compliance with federal regulatory statutes. The general inpatient and outpatient training environment for pediatric cardiology fellows must provide full opportunity for observation, acquisition, and application of these skills by the trainee.During the course of inpatient and outpatient activities the pediatric cardiology fellow will become familiar with a core knowledge base, as outlined in Table 1, at a minimum.The program should offer courses, seminars, workshops, and/or laboratory experiences to provide appropriate background in basic and fundamental disciplines related to the heart and cardiovascular system. A lecture series encompassing a core curriculum in clinical and basic science topics must be provided for pediatric cardiology fellows. It should be designed so that the spectrum of topics presented will be completed at least once in the three years of accredited fellowship training. Pediatric cardiology fellows should contribute formal presentations of selected topics in the core curriculum, both to strengthen their knowledge base and to develop formal presentation skills. General areas to be covered in the core curriculum include those listed in Table 1.Preoperative conferences with the cardiovascular surgical service are essential. Journal clubs are a recommended element of an academic environment and provide an excellent venue for participatory evaluation of study design and data analysis. Quality assurance evaluation and morbidity/mortality conferences should be held periodically. Multidisciplinary clinical and research conferences are highly desirable; according to the strengths of the institution, contributors might include neonatology, cardiothoracic surgery, adult cardiology, cardiac pathology, physiology, pharmacology, pulmonology, intensive care, cardiac anesthesiology, cardiovascular radiology, clinical genetics, molecular genetics, tissue engineering, stem cell biology, or developmental biology. In all of these conferences, pediatric cardiology fellows should be provided with active roles appropriate to their level of knowledge and training.It is a fundamental responsibility in academic medicine that those with the most experience must teach. The pediatric cardiology fellow will often be the most clinically experienced house officer on a team of residents, interns, and/or medical students. The fellow in that setting should be expected to provide lectures/seminars to the team of house officers. The pediatric cardiology fellow should also be allowed the opportunity to practice clinical leadership, organizational skills, and impromptu educational activities as appropriate to his/her demonstrated level of knowledge and training. There should be occasion for observation and critique of these skills by the attending physician as well as demonstration of these skills to the fellow by the attending.Pediatric cardiology fellows should develop formal evaluation of trainees and training skills during their fellowship. To do so, they should participate in feedback to residents, students, and cardiology attendings throughout their rotations regarding their own educational and technical progress and the progress of other team members. Accurate self-evaluation is the most valuable skill of all and should be nurtured in all phases of pediatric cardiology training.The authors of this section declare they have no relationships with industry pertinent to this topic.Noninvasive imaging, including echocardiography and magnetic resonance imaging (MRI), is a primary means for elucidating the anatomy and physiology of childhood heart disease. Competence in performance and interpretation of echocardiography and MRI is now essential to the practice of pediatric cardiology. Depending upon one’s individual career goals, varying levels of expertise may be expected to be achieved during fellowship training. This document defines the levels of knowledge and expertise that pediatric cardiology trainees should acquire in echocardiography and MRI during training, and it offers guidelines for achieving these levels of competence.Training guidelines have been previously published for pediatric echocardiography,1 fetal echocardiography,2 and pediatric transesophageal echocardiography.3 Those documents were reviewed and considered during preparation of these guidelines. The guidelines presented here differ in some instances from previous recommendations because this task force recognizes that training programs have changed significantly over the decade since the last guidelines were promulgated.Echocardiography, as used in this document, includes two-dimensional imaging of the heart and related structures, M-mode echocardiography for assessment of chamber size and function, color M-mode and Doppler tissue and flow mapping, pulsed and continuous-wave spectral Doppler flow analysis, and other variations of these basic modalities used to assess the structure and function of the heart and related organs, including new technologies such as three-dimensional echocardiography as they become available.The pediatric echocardiography laboratory should serve a hospital with inpatient and outpatient facilities, neonatal and pediatric intensive care units, a pediatric cardiac catheterization/interventional laboratory, and an active pediatric cardiac surgical program. The pediatric echocardiography laboratory should be under the supervision of a full-time pediatric cardiologist-echocardiographer qualified to direct a laboratory, and whose primary responsibility is supervision of the laboratory. The laboratory must perform a sufficient number of pediatric transthoracic, pediatric transesophageal, and fetal echocardiograms1,4 each year to allow trainees sufficient exposure to both normal and abnormal examinations.Training goals defined here are to enable trainees to achieve one of two levels of expertise in echocardiography as appropriate for career goals.Core training should be achieved by all pediatric cardiology fellows during core clinical training, typically during four to six months dedicated to echocardiography over the course of the standard three-year training program. This level of expertise is anticipated to be sufficient for those fellows who do not plan to pursue echocardiography as an area of subspecialization.Advanced training requires an additional 9 to 12 months of training and may be achieved through a dedicated experience in pediatric echocardiography after completion of core pediatric echocardiography instruction. This level of training is appropriate for those physicians who intend to be dedicated pediatric echocardiographers.Successful completion of each training level should result in competence in the following specific areas.In addition to core competencies, other goals include: Each level of training may be achieved by the methods outlined in the following text or by comparable alternative methods. A summary of the recommended minimum number of procedures is found in Table 1.Each trainee should perform and interpret at least 150 pediatric echocardiograms, including at least 50 in patients one year of age or younger, under the supervision of the laboratory director or other qualified staff pediatric cardiologist-echocardiographer(s). Each trainee should also review at least 150 additional pediatric echocardiograms.In addition, the laboratory director or other staff pediatric cardiologist-echocardiographer(s) should conduct regular laboratory conferences with the trainee(s) to present illustrative cases and to teach proper interpretation and the limitations of echocardiography. Pathological specimens, models, or photographs for echocardiographic-anatomic correlation are excellent teaching aids that should be incorporated wherever possible.Integration of echocardiography into the clinical practice of pediatric cardiology should be demonstrated on inpatient and outpatient rotations and at medical-surgical management conferences.Research training for pediatric cardiology trainees should include active participation in reviews of scientific journal articles that pertain to echocardiography.Each advanced-level trainee should perform and interpret at least 200 additional pediatric transthoracic echocardiograms and review, or perform and interpret, another 200 pediatric echocardiograms. As with core training, at least 50 of these should be done in infants one year of age or younger. Each trainee should perform a significant number of echocardiograms independently (one-third to one-half of the exams), with subsequent review and critique of the examination by the responsible staff pediatric cardiologist-echocardiographer. Teaching methods outlined in the previous text should be continued here.Each advanced-level trainee should perform and interpret at least 50 pediatric transesophageal echocardiograms, including manipulation of the transducer and registration of images, under direct supervision by a dedicated pediatric cardiologist-echocardiographer. The trainee should perform intubation of the esophagus in at least 20 patients under the direct supervision of a pediatric cardiologist-echocardiographer or anesthesiologist experienced in the procedure. An ideal environment for learning pediatric transesophageal echocardiography is the operating suite during performance of intraoperative examinations, but the training experience should not be limited to this venue and should include the intensive care unit, cardiac catheterization suite, and outpatient examinations.Each advanced trainee should perform and/or review at least 50 fetal echocardiograms. The trainee must master the fundamental skills of determining fetal position, situs, cardiac anatomy, and cardiac rhythm under the supervision of a dedicated pediatric cardiologist-echocardiographer. The trainee should observe and participate in the discussion of the findings with the parents by the staff echocardiographer responsible for the examination. As the trainee’s experience progresses, a significant proportion (30% to 50%) of studies should be performed independently, including cases with normal and abnormal cardiac anatomy and rhythm, with supervision by a dedicated pediatric cardiologist-echocardiographer. Each trainee should understand how to recognize and approach fetal heart failure, and he or she should understand the association of fetal heart disease with extracardiac structural abnormalities, syndromes, and chromosomal abnormalities.Research training for pediatric cardiology trainees should include, at a minimum, active participation in reviews of scientific journal articles that pertain to echocardiography. In addition, participation in basic or clinical research in echocardiography should be encouraged.Each advanced-level trainee should be given responsibility for participating in the training of sonographers and junior pediatric cardiology fellows, initially with supervision of the laboratory director and then independently and also presenting echocardiography-related teaching conferences and formal didactic lectures.The laboratory director, in consultation with the teaching staff, should evaluate each trainee in writing on a regular basis. Trainees should maintain a log of all echocardiograms performed and reviewed, including the age of the patient and the diagnosis. The log should be reviewed regularly by both the laboratory director and the training program director to ensure that each trainee is obtaining adequate and balanced experience.The evaluation should be reviewed with each trainee and a written copy provided. If a trainee does not appear to be progressing adequately during the rotation, a meeting should be scheduled as soon as possible to inform the trainee and to discuss potential remedial measures. The evaluation should be based on achievement of the expected levels of competence in the areas outlined in the previous text.Direct observation of the trainee during performance of echocardiograms provides information about imaging skills and understanding of the ultrasound instruments. Conferences in which echocardiograms are presented provide an opportunity to assess skills in interpretation of images and Doppler recordings. The trainees’ understanding of research design and methods and ability to review research can be critically evaluated during journal club meetings or other venues for medical literature review. Teaching skills and effectiveness can be evaluated by direct observation and from evaluations by sonographers and more junior trainees and by performance at teaching conferences prepared and delivered by trainees.Magnetic resonance imaging (MRI) as used in this document includes anatomic and functional cardiovascular MRI in congenital and acquired pediatric heart disease as well as in the adult with congenital heart disease. At present, there are no specific guidelines for training or credentialing in pediatric cardiovascular MRI. It is likely that the training guidelines for pediatric cardiovascular MRI proposed here will require amendment as the field evolves. These guidelines must be considered as goals and should not be considered as requirements.Trainees may achieve one of two levels of expertise in pediatric cardiovascular MRI as appropriate for career goals.Training in pediatric cardiovascular MRI should occur within a pediatric cardiology fellowship program and/or a pediatric radiology training program accredited by the Accreditation Council for Graduate Medical Education (ACGME). The MR laboratory should serve a hospital with both inpatient and outpatient facilities, neonatal and pediatric intensive care units, a pediatric cardiac catheterization/interventional laboratory, and an active pediatric cardiac surgical program. The MRI laboratory should be under the supervision of a full-time cardiologist and/or radiologist qualified in cardiovascular MRI, and it must perform a sufficient number of annual examinations to allow each trainee sufficient exposure to both normal and abnormal examinations.Core training should be achieved by all pediatric cardiology fellows during the core clinical years of the program. This level of expertise may be sufficient for those fellows who plan to practice clinical pediatric cardiology with access to a pediatric cardiologist or radiologist with special expertise in pediatric cardiovascular MRI.Advanced training requires a minimum of six months of instruction in addition to core training. This level of training is appropriate for those physicians who intend to have special expertise in pediatric cardiovascular MRI and is recommended for directors of pediatric cardiovascular MRI laboratories.Successful completion of each training level should result in competence in the following specific areas.Each level of training may be achieved by the methods outlined in the following text or by comparable alternative methods.Pediatric cardiology trainees should gain exposure to cardiovascular MRI through active review of scientific journal articles that pertain to pediatric cardiovascular MRI, discussion with cardiologists and radiologists who perform cardiovascular MRI, and, if possible, review of cardiovascular MRI examinations.During a fellowship in pediatric cardiovascular MRI, each trainee should perform and/or interpret at least 100 cardiovascular MRI examinations in patients with congenital or acquired childhood heart disease, including adult patients with congenital heart disease. As the trainee’s experience progresses, an increasing proportion of these examinations should be performed independently, with review and critique by the laboratory director.Research training should include continued critical review of the pediatric cardiovascular MRI literature and an opportunity to perform basic or clinical research leading to publication or presentation of scientific data.Each trainee should be given responsibility for participating in the training of technologists and junior pediatric cardiology fellows, initially with supervision of the laboratory director and subsequently independently. In addition, each trainee should have opportunities to observe and participate in the management of the laboratory, especially quality improvement initiatives.The laboratory director, in consultation with the teaching staff, should evaluate each trainee in writing. The evaluation should be reviewed with each trainee and a written copy provided. The trainee should maintain a log of all examinations performed and reviewed, including the age of the patient, diagnosis, and role of the trainee in the examination.The authors of this section declare they have no relationships with industry pertinent to this topic.The purpose of this document is to recommend minimum training experiences in cardiac catheterization for clinical fellows in pediatric cardiology training programs. Training guidelines in cardiac catheterization are well-established in adult cardiovascular medicine,1,2 and they have been considered recently in pediatric cardiology as well.3,4Pediatric cardiac catheterization is a unique specialty encompassing a wide range of diagnostic and therapeutic techniques applied to a diverse group of congenital and acquired cardiovascular disorders. A physician who performs a pediatric cardiac catheterization must possess the technical skills and clinical judgment to safely and accurately perform a thorough diagnostic cardiac catheterization and angiographic study. Furthermore, an interventional pediatric cardiologist must also assess the indications for a catheter intervention, including the risks of performing or not performing the procedure (i.e., requires knowledge of the natural history of the defect), and must skillfully perform the appropriate catheter intervention. It is appropriate, therefore, to delineate minimal training requirements in cardiac catheterization for pediatric cardiology trainees.There are no studies relating training experiences to subsequent clinical skill in pediatric cardiac catheterization. Therefore, the recommendations in Task Force 3 represent the opinions of the authors. To help guide this process, all Accreditation Council for Graduate Medical Education (ACGME)-accredited pediatric cardiology training programs were surveyed in 2001 to inquire about current practices and opinions regarding fellow training in pediatric cardiac catheterization and intervention. Thirty-two programs responded. The responses represented the opinions of fellowship directors (n = 21), catheterization laboratory directors (n = 15), and division directors (n = 13) (in some programs one individual holds more than one position). This document draws on this Training Program Survey to help define training guidelines in this specialty.Training in cardiac catheterization should occur within a pediatric cardiology fellowship program that is accredited by the ACGME. The cardiac catheterization laboratory should serve a hospital with inpatient and outpatient facilities, neonatal and pediatric intensive care units, and an active pediatric cardiac surgical program. The pediatric cardiac catheterization laboratory should be under the supervision of a full-time pediatric cardiologist, whose primary responsibility is supervision of the laboratory. The laboratory must perform a sufficient number of cardiac catheterizations and interventional procedures to provide each trainee with an acceptable experience.The cardiac catheterization program must have a regular teaching conference in which diagnostic data (hemodynamic and angiographic) and therapeutic outcomes are formally discussed. In addition, each program that provides advanced interventional training must have a regular morbidity and mortality conference in which all adverse outcomes of catheter interventions are systematically reviewed. Participants in this conference should include cardiology faculty, clinical fellows, and preferably pediatric cardiothoracic surgeons and cardiac anesthesiologists. Active part