Expertise in Pediatric Cardiac Anesthesia Begins With Well-Designed Training Programs

Abstract

The subspecialty of pediatric cardiac anesthesia began in concert with the early history of congenital heart surgery.1Nasr VG Hickey PA Hansen DD. History of anesthesia for congenital heart disease.Anesthesia for congenital heart disease. John Wiley & Sons, Ltd, 2015: 1-15Crossref Scopus (1) Google Scholar In 1938, Dr. Robert E. Gross first ligated the patent ductus arteriosus of a patient in the United States, and the disciplines of pediatric cardiology and cardiac surgery were born. Six years later, Alfred Blalock anastomosed the left subclavian artery to the pulmonary artery in a patient with tetralogy of Fallot, opening the possibility of palliating cyanotic lesions. Simultaneously, surgical advances were occurring in Europe, with the first successful repair of a coarctation of the aorta with an end-to-end anastomosis performed by Crayfoord and Nylin.2Hernandez Conte A History of pediatric anesthesia and pediatric cardiac-congenital surgery.in: Dabbagh A Conte A. Lubin L. Congenital heart disease in pediatric and adult patients. Springer International Publishing, Switzerland2017Crossref Scopus (1) Google Scholar With advances in cardiac surgery and cardiology, pediatric cardiac anesthesia also has experienced significant evolution and growth, and emerged as a distinct field requiring specialized training.1Nasr VG Hickey PA Hansen DD. History of anesthesia for congenital heart disease.Anesthesia for congenital heart disease. John Wiley & Sons, Ltd, 2015: 1-15Crossref Scopus (1) Google Scholar Early training in pediatric cardiac anesthesia was founded on self-declared interest gained through exposure during residency or as a staff member gaining “mentored” experience while caring for patients with congenital heart disease.3Nasr VG Guzzetta NA Mossad EM. Fellowship training in pediatric cardiac anesthesia: History, maturation, and current status.J Cardiothorac Vasc Anesth. 2019; 33: 1828-1834Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Several training models developed through the 1990s, with Boston Children's Hospital and Children's Hospital of Philadelphia establishing formal curricula. In Europe, the first published statement on the need for training for all members of the team was triggered by significantly higher mortality rates following children's cardiac surgery in the Bristol Royal Infirmary from 1984 to 1995 compared with other centers.4Kennedy I. The report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary 19841995. Available at: http://webarchive.nationalarchives.gov.uk/20090811143822/http://www.bristol-inquiry.org.uk/final_report/the_report.pdf. Accessed September 12, 2020.Google Scholar The Report of Pediatric and Congenital Cardiac Services Review Group in Great Britain, published in 2003, proposed that the anesthesiologist involved in pediatric and congenital cardiac surgery should, similarly to the surgeons and cardiologists, have a minimum standard of training experience.5Report of the Pediatric and Congenital Cardiac Services Review Group, London. Available at: https://webarchive.nationalarchives.gov.uk/ukgwa/20120503132544/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4070817?ssSourceSiteId=ab. Accessed September 7, 2021.Google Scholar It was not until 2010 that DiNardo et al. proposed two distinct pathways for training in the United States: one based on nine months of core training in pediatric cardiac anesthesia after completion of a 12-month pediatric anesthesia fellowship or adult cardiothoracic anesthesia fellowship, and the second based on 18 months of combined training in both pediatric anesthesia and pediatric cardiac anesthesia.6DiNardo JA Andropoulos DB Baum VC. Special article: A proposal for training in pediatric cardiac anesthsia.Anesth Analg. 2010; 110: 1121-1125Crossref PubMed Scopus (25) Google Scholar This publication set the foundation for what would become the 2014 recommendations by the Pediatric Anesthesia Leadership Council and the Congenital Cardiac Anesthesia Society (CCAS), advocating for an accredited second year advanced fellowship in pediatric cardiac anesthesia.7Andropoulos DB Walker SG Kurth CD et al.Advanced second year fellowship training in pediatric anesthesiology in the United States.Anesth Analg. 2014; 118: 800-808Crossref PubMed Scopus (19) Google Scholar In 2018, the CCAS published a consensus statement on milestones for pediatric cardiac anesthesia fellowships, defining 18 milestones as competency-based development outcomes based on the Accreditation Council on Graduate Medical Education (ACGME) Milestones Model.8Nasr VG Guzzetta NA Miller-Hance WC et al.Consensus statement by the Congenital Cardiac Anesthsia Society: Milestones for the pediatric cardiac anesthesia fellowship.Anesth Analg. 2018; 126: 198-207Crossref PubMed Scopus (10) Google Scholar This article written by an expert panel of members of the CCAS and the Society of Pediatric Anesthesia became the first template for pediatric cardiac anesthesia training programs in the United States, with the intent of defining educational and performance-based criteria for graduation and recommending 12 months of training in pediatric cardiac anesthesia. In Europe, similar efforts to define the length of training and caseload were undertaken. In the United Kingdom, the majority of anesthesiologists spent at least 18 months of training after general pediatric anesthesia training. The additional training consisted of six months in adult cardiac anesthesia, six months in pediatric intensive care, and six months in pediatric cardiac anesthesia.9White MC Murphy TW. Postal survey of training in pediatric cardiac anesthesia in the United Kingdom.Paediatr Anaesth. 2007; 17: 421-425Crossref PubMed Scopus (15) Google Scholar Similarly, a working group representing the German Society for Anesthesiology and Intensive Care surveyed all pediatric cardiac centers in Germany, and 12 months of training was the most common.10Baehner T Dewald O Heinze I et al.The provision of pediatric cardiac anesthesia services in Germany: Current status of structural and personnel organization.Paediatr Anaesth. 2017; 27: 801-809Crossref PubMed Scopus (9) Google Scholar However, consistent educational content, clinical exposure, and performance evaluation guidelines did not exist. Given the growth of pediatric cardiac anesthesia as a specialty, the complexity of patient care, and the substantial variability in training duration, clinical experience, and didactic content of existing programs, the CCAS/Society of Pediatric Anesthesia in the United States and the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) both have moved toward standardizing the curriculum and further seeking accreditation for the subspecialty. In this edition of the Journal, the EACTAIC proposed a curriculum for training in pediatric cardiac anesthesia.11European Association of Cardiothoracic Anaesthesiology and Intensive Care Pediatric Cardiac Anesthesia Fellowship Curriculum: First edition. 2021.Google Scholar The EACTAIC Educational Committee established a task force to develop this first edition of the curriculum. The task force had the benefit of learning from the EACTAIC adult training program in cardiac, thoracic, and vascular anesthesia, which was established in 2009.12Erdoes G Vuylsteke A Schreiber JU et al.European Association of Cardiothoracic Anesthesiology (EACTA) Cardiothoracic and Vascular Anesthesia Fellowship Curriculum: First Edition.J Cardiothorac Vasc Anesth. 2020; 34: 1132-1141Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In this adult program, there currently are 20 certified fellowship positions in ten hosting centers within seven European countries, with two positions outside Europe (Sao Paulo, Brazil). Since 2009, 42 fellows have completed the fellowship training.13El Tahan MR Vasquez LE M Rp A et al.Perspectives on the fellowship training in cardiac, thoracic, and vascular anesthesia and critical care in Europe from program directors and educational leads around Europe.J Cardiothorac Vasc Anesth. 2020; 34: 512-520Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Building on this adult training framework, the task force undertook two surveys addressed to the members of the EACTAIC education committee and used a modified Delphi method to determine and agree on the recommended length and scope of training in pediatric cardiac anesthesia and the knowledge and technical skills required for successful completion of training. In the United States, the medical specialty and subspecialty programs mostly seek accreditation by the ACGME. The ACGME is an independent, not-for-profit, physician-led organization that sets and monitors the professional educational standards essential in preparing physicians to deliver safe, high-quality medical care to all Americans. The process for ACGME accreditation for pediatric cardiac anesthesia in the United States started with a proposal by the CCAS task force requesting recognition of the specialty. The proposal was posted online for 45 days to allow feedback by the public.14Available at: https://www.acgme.org/What-We-Do/Accreditation/Review-and-Comment/Accessed September 12, 2021.Google Scholar After feedback and review by the ACGME, approval of and recognition of the subspecialty were issued. A subspecialty-specific committee then was established to develop program requirements. The ACGME posted the program requirements and invited comments from the community of interest regarding the proposed requirements. The program requirements now are undergoing a series of modifications and enhancements until a final program requirement addressing all concerns by the community and the Review Committee is established. The program requirements then will be available for all programs and the application process for individual programs can be initiated. The EACTAIC proposal suggests one year as the minimum duration of training and 100 surgical cases as the minimum number of patients that would be required for completion of a pediatric cardiac anesthesia fellowship. Similarly, the duration of the ACGME-accredited fellowship for pediatric cardiac anesthesia in the United States is one year. The current suggested surgical cases in the United States is 100. However, the recommended number of surgical and interventional and diagnostic catheterization cases will be finalized by the ACGME program development committee in 2021. The Union Européenne des Médicins Spécialistes strongly supports the concept that the quality of medical care and expertise is linked directly to the quality of training provided to medical professionals.15Kietaibl S Blank A De Robertis E. Medical training in anaesthesiology: Updated European requirements.Eur J Anaesthesiol. 2019; 36: 473-476Crossref PubMed Scopus (6) Google Scholar No matter where doctors are trained, they should have the same core competencies. What is clear is that training in pediatric cardiac anesthesia requires a foundation in anesthesiology, which includes training in adult anesthesia, pediatric anesthesia, and intensive care, before embarkine upon subspecialty training. Every country will have their own specific pathways for this foundation training. The EACTAIC pediatric cardiac anesthesia program defined a prerequisite of fellowship training or work experience for one year in adult cardiac anesthesia and one year of pediatric anesthesia at a nationally or internationally recognized center with dedicated care for this patient population. Similarly, in the United States, the current requirement to join the dedicated second-year fellowship in pediatric cardiac anesthesia is completion of a pediatric anesthesia fellowship or adult anesthesia fellowship with pediatric anesthesia experience. It also is evident that programs offering subspecialty training in pediatric cardiac anesthesia should agree on the core knowledge and skills required to practice. The EACTAIC proposal used a traffic-light system to obtain consensus from experts in pediatric cardiac anesthesia to create their core requirements. This was similar to the consensus statement of proposed milestones for training in pediatric cardiac anesthesia by the CCAS in the United States.8Nasr VG Guzzetta NA Miller-Hance WC et al.Consensus statement by the Congenital Cardiac Anesthsia Society: Milestones for the pediatric cardiac anesthesia fellowship.Anesth Analg. 2018; 126: 198-207Crossref PubMed Scopus (10) Google Scholar Of note, the age spectrum of patients with congenital heart disease who require the specialist services of a congenital cardiac team is from birth to adulthood. Therefore, the term congenital cardiac anesthesiology frequently is used interchangeably with pediatric cardiac anesthesia. This subtle difference may have future implications for both foundation training and subspecialty training as children born with complex congenital heart disease survive to adulthood. The EACTA recommendation currently states “simultaneous management of adults with congenital heart disease (ACHD) is encouraged and should be considered in the center's PCA certification process whenever possible.” What is more difficult to ascertain is how long does it take to become an “expert” in pediatric cardiac anesthesia? The author Malcolm Gladwell popularized the idea that it takes 10,000 hours of practice to become an expert at something.16Gladwell M. Outliers: The Story of Success.1st ed. Little, Brown and Co, New York2008Google Scholar If this is believed, then subspecialty training in pediatric cardiac anesthesia should take about 1,000 ten-hour days or around four-to-five years if trainees are allowed weekends off and vacation time. Hence, the goal of training programs in pediatric cardiac anesthesia should not be to create experts by the end of the one-year fellowship, but safe and competent specialist anesthesiologists who will continue to be adult learners and will gain expertise throughout their practice years. These early years of independent clinical practice should be accompanied by dedicated faculty development initiatives and mentoring at all levels including academic, education, clinical, and administrative. Dedication to patients with congenital heart disease, commitment to multidisciplinary teams, and a passion for continual learning are all key components to achieve and maintain expertise in pediatric cardiac anesthesia. None.