The Future of Cardiovascular Education and Training
In this review, we will attempt to envision not just emerging changes in training in each of our specialties, but also some of the general directions in which the field of postgraduate medical education will evolve. Although the formal training programs in our professional areas are at distinctive phases in the transition from a traditional time-limited apprenticeship model to one that is focused on the quantitative assessment of competency, they each share the burdens of adapting to increasingly rapid change in the fundamental knowledge base and in patterns of care delivery. These challenges come at a time when there is increasing uncertainty in reimbursement and job security for clinicians in cardiovascular disease. We have tried to highlight specific developments in the relevant sections, but it is clear that the external and internal pressures in each cardiovascular specialty and our responses to these pressures overlap considerably. By learning from each other and adopting best practices, we will be better able to cope with the inevitable change that professional education promises in the next decade and beyond.
The Future of Training in Pediatric Cardiology
The education and training of physicians in pediatric cardiology continues to evolve with a recent paradigm shift in training from proscriptive time-based or procedural number-based recommendations for training to competency-based objectives. The 2015 training guidelines for Pediatric Cardiology programs were revised by task force members that included representatives from all relevant professional societies (American Academy of Pediatrics, American College of Cardiology, and American Heart Association) and the Society of Pediatric Cardiology Training Program Directors.1 The 2015 guidelines highlight the paradigm shift toward competency. Although previous guidelines were based on the assumption that competency for given activities, tasks, or procedures would naturally follow from proscriptions of months of exposure and numeric targets, the new guidelines reflect the reality that it is competence that is the goal of training, and that there is wide variation in how and when this develops among learners. The Accreditation Council for Graduate Medical Education (ACGME) has delineated 6 core competency categories that they expect to be included in training paradigms. The 8 Task Force Reports that form the new Pediatric Cardiology 2015 guidelines2–9 make major strides in moving away from defining minimum time and numeric-exposure targets and in defining what the specific goal competencies for both categorical and advanced training are. However, moving forward, training program directors and clinical competency committees face the monumental challenge of how to accurately and continuously measure competence in our trainees.
Measuring Outcomes of Training
One of the current barriers to the assessment of trainees in pediatric cardiology is the lack of appropriate tools and instruments with which to evaluate competence. In-service examinations and board examination scores may be reliable and reproducible in assessing medical knowledge, but address only 1 domain of competence and fall short of assessing overall clinical performance. Current iterations of the 360-degree evaluation, including direct faculty observation and self-assessment, are important, but remain subjective, entirely dependent on time-and-chance encounters in the clinical environment, and insufficient to allow for the adequate assessment of competence. Competency assessment tools modeled after the objective, structured clinical examination10 have begun to be developed in pediatric cardiology, such as 1 recently described assessment exercise in the performance and interpretation of pediatric echocardiography.11 The future development of similar evaluation exercises will be important tools in assisting both trainees and mentors in gauging progress toward competence.
Another important future assessment tool involves the development of entrustable professional activities (EPAs) in pediatric cardiology. Although competencies are person descriptors that include knowledge, ability, attitude, and values, EPAs are work descriptors that outline the essential tasks necessary for professional practice.12 The level of supervision to perform those work tasks reflects the increasing trust in trainee autonomy as they progress from novice to expert, and the degree of entrustment defines the assessment. Although it may seem an easy task at first blush, developing and enumerating the specific work tasks that one would expect an adequately trained categorical fellow to be able to do independently on completion of his training is quite difficult. An effort to develop EPAs for pediatric cardiology is currently being undertaken by the Society of Pediatric Cardiology Training Program Directors working with The American Board of Pediatrics. Once EPAs have been established, further work will be required to evaluate their performance as assessment and evaluation tools.
The current training environment in pediatric cardiology is marked by an era of decreased trainee autonomy, increased work-hour restrictions, and across-the-board expansion of in-house attending physician coverage. The rise of the patient safety movement and the increasing focus of hospitals and payers on healthcare quality over the past decade have no doubt markedly improved medical care and patient outcomes, but have also had considerable impact on training. The trainee work-hour restrictions put in place by the ACGME in 2003, and then expanded in 2011, have placed pressure on the pediatric cardiology trainees in the form of increasing patient handoffs and decreased time to refine procedural competencies, among others. Although the ACGME and others are currently gathering data on the impact of work-hour restrictions on patients and trainees, including 2 large randomized trials in surgery and internal medicine training programs, some form of work-hour restrictions is likely to remain. In addition, the balance of trainee autonomy has shifted further toward supervision, and is not likely to shift back toward autonomy. Increased supervision has positive aspects, including improved opportunities for teachers and mentors for interaction, for direct observation, for evaluation, and for feedback; and the ability to model professional behaviors. However, increased supervision is at tension with the notion of graduated responsibility, and can make it difficult for supervisors to award greater degrees of entrustment as trainees progress toward independence. This can result in a lack of readiness in the fellow-to-faculty transition and likely results in increased stress during the initial years of clinical practice. Training programs of the future will need to innovate within the confines of duty-hour restrictions and increased supervision requirements to encourage forms of graduated responsibility and independent practice.
Dedicated Early Instructional Periods
The practice of pediatric cardiology requires a unique knowledge base, and procedural and diagnostic skills, as well, to which pediatric residents traditionally have limited exposure during residency training. Most pediatric residents have little knowledge of complex cardiac anatomy and physiology and virtually no hands-on exposure to echocardiography, invasive/interventional cardiology, and electrophysiology. Despite this limitation, in most current training programs, beginning fellows arrive and are expected to start rapidly integrating into these highly technical clinical environments, caring for patients with complex physiology despite little formal training. Acquisition of core skills may be delayed when introduction of these concepts relies on time-and-chance exposure in the clinical environment, compounded by work-hour restrictions. Dedicated instructional time early in training, so-called boot camps, have been used by procedural-oriented training programs such as pediatric critical care medicine and orthopedics, otolaryngology, and cardiothoracic surgery, as well; these allow the rapid introduction of key knowledge and skills so that trainees can become rapidly functional and safe in the clinical setting. A meta-analysis of such boot camps has shown that these programs lead to significant improvements in clinical skills, knowledge, and confidence.13 Some of the objectives of these bootcamps include introduction of core clinical content, acquisition of fundamental procedural skills, orientation to hospital policy and procedure, and team building. Such dedicated instructional time has also been advocated as a way to mitigate the July effect, a decrease in efficiency and increase in adverse outcomes seen in some hospital settings at the onset of the academic year.14 As our field continues to advance in the technical and therapeutic complexity, the future of pediatric cardiology training will likely involve increasing expansion of these types of early intensive periods early in training.
Simulation-based training offers the ability to learn and practice key procedural skills in a simulation environment free of risk for patient harm. Simulation training is often perceived by learners as an effective learning methodology, and has been successfully used to address high-risk procedures or clinical scenarios that have been traditionally taught by the see one, do one, teach one approach. The simulation environment has also been associated with positive instructional behaviors, in particular, in procedural fields, where high acuity, time pressure, and task fixation in the live setting may impair instructional technique. Improved patient outcomes have been linked to the use of simulation-based education with deliberate practice in comparison with traditional educational approaches in central venous catheter placement.15 There are several skills relevant to pediatric cardiology training that would benefit from the further expansion of simulation training, including catheterization skills such as vascular access, catheter manipulation, balloon atrial septostomy; imaging skills such as learning appropriate transthoracic and transesophageal views; and intensive care unit skills such as airway management and crisis resource management (eg, code blue) drills.
As electronic medical records have gradually moved into and become pervasive in both hospital and outpatient environments, training program supervisors and trainees alike now have the opportunity to harness the medical record to assist with training assessment and adaptation. The opportunity to track electronically the exposure and progress of trainees is now unprecedented, and goes far beyond the functionality of the typical procedural log. Most electronic medical records now have the ability to generate the age, diagnoses, site of care, and even treatment codes for patients encountered in various settings; this offers the remarkable opportunity to move beyond accidental time-and-chance encounter education to intentional education to create truly individualized education opportunities for our trainees. The creation and integration of robust informatics tools into intentional training and evaluation will be an important focus of training in the future.
From Fixed to Flexible Time
The natural extension of the transition from fixed time-duration training to competency-based training is the dissolution of the traditional pediatric cardiology model of 3 years of categorical training with an optional additional fourth year subspecialty training. As training programs move toward full acceptance of this approach to training, we will need the ability to shorten and lengthen individuals’ training programs to meet their needs based on their progress toward independent practice. Currently, the regulatory bodies such as the ACGME and American Board of Pediatrics have not yet moved beyond the traditional time-duration model of training to allow for board certification, although the development of the pediatric cardiology–specific EPAs will likely help push this issue forward. Although there are no formal American Board of Pediatrics certifications for sub-subspeciality training such as imaging, catheterization, and electrophysiology, there are efforts underway by organizations such as the American Society of Echocardiography to set standards for training, and optional certifications in this regard will likely expand. Training programs in the future will also need to develop innovative care models that can appropriately accommodate flexible duration training schedules, while at the same time meeting service demands.
Multiple Career Paths
As the field of pediatric cardiology has grown and matured, the number and shape of possible career paths has broadened considerably. In addition to a sub-subspecialty area of focus, trainees today may contemplate an academic career as a basic investigator, clinical investigator, clinician-educator, clinician-scholar, quality improvement specialist, or administrator. Each of these requires additional focused training and skill sets that are well beyond the focus of the traditional categorical training program. Training programs in the future will continue to need to revisit the definition of what constitutes that minimum core training required for every pediatric cardiologist, and what types of supporting activities could be selected to prepare trainees for their particular focus of choice.
The training programs of the future will need to continue to adapt and adjust to learners who want to train in a system that promotes work–life balance and integration. Although the attention to duty hours over the past decade has been largely driven by the patient safety movement and measured in terms of patient-care metrics, more attention is now focused on and will continue to focus on the effects of those restrictions on learners’ quality of life and educational outcomes. A recent study found that almost one-third of residents exhibit symptoms of depression,16 and physician burnout is common among trainees. Clearly, training programs of the future will need to help learners adapt to the reality of the intense work demands in cardiovascular medicine, while at the same time teaching them to moderate their pace, pay attention to work–life balance, and maintain personal and emotional relationships.
The Future of Training for Adult Cardiovascular Medicine
The paradigm for clinical training in internal medicine and its subspecialities has changed little since Osler and remains, in essence, a time-limited apprenticeship. In cardiovascular medicine, this apprenticeship now occurs after formal training in internal medicine and within an accredited cardiovascular training program regulated by the ACGME. This program has competence thresholds set by a combination of subjective peer evaluation and by the board eligibility examinations under the jurisdiction of the American Board of Internal Medicine. The current consensus on the subject matter for categorical training in cardiovascular medicine is derived from a series of independent professional conferences entitled the Core Cardiology Training Symposia, each convened by the American College of Cardiology.17–33 These consensus conferences have typically set targets for the balance of clinical exposures and procedural volumes, although they occur on an infrequent cycle and at times have not completely matched evolving practice. In cardiovascular medicine there has been a proliferation in subspecialization with interventional cardiology, cardiac electrophysiology, heart failure, and, most recently, adult congenital heart disease, now each with independent board examinations. In addition, other areas of burgeoning subspecialization, including cardiovascular imaging, cardiac prevention, lipid management, inherited heart disease, cardiac critical care, and cardio-oncology, are emerging.
Cardiovascular medicine evolved as an off-shoot of internal medicine, and, over the past few decades, many of the trends in medical education and training have appeared first in that parent community. As a result, several developments can be inferred for the near term, including: milestone-limited training, new context-specific training programs (eg, inpatient versus outpatient), increased use of simulation technologies, and the implementation of continuous forms of competence assessment. Although each of these innovations has a specific rationale and has emerged from very specific training needs, the paradigm in which these changes will be implemented remains quite traditional. The next few years may see much more radical changes in health care, and, thus, any strategic planning for the future of training for cardiovascular medicine must also take account of the need for adaptability.
Dealing With New Demands
As this expansion of cardiovascular training has taken place, so has the knowledge base necessary for a typical cardiologist to practice grown exponentially, and the challenges of maintaining a fully competent cardiology workforce have accumulated in parallel. Yet, biomedicine as a field has largely been shielded from the monumental changes that have shaken other areas of professional endeavor. In the past year, although the full impact of genomics and personalized medicine has still to be felt, the stream of new information and new therapeutics that must be incorporated into daily practice already overwhelms traditional approaches to medical education, runs past current strategies for professional consensus building such as guidelines, and may make empirical practices of the past obsolete overnight.
In parallel with the ever-changing scope of medical specialty practice, disease demographics are changing in ways that will soon directly affect the cardiology workforce. The incidence of coronary artery disease is falling steadily where lifestyle changes and statins have penetrated, at the same time as myocardial infarction increases where industrialization is taking place. Even congestive heart failure, the final common pathway for so much of cardiac and vascular disease, appears to have reached a plateau.34 As these major epidemics level off, new disorders and new procedures place demands on the cardiologist. Atrial fibrillation, aortic valve disease, and cardiomyopathy are increasingly common, whereas diagnoses such as infection of implanted devices and the new toxicities of molecular oncology therapeutics are beginning to affect general cardiology practice. Cardiology successes in prevention and in understanding population biology have positioned the specialty to move into metabolic disease and into inflammation. A focus on health, the quantified-self movement, and the public desire to pursue wellness actively are all aligned with major interest areas within modern cardiovascular medicine.35 This convergent evolution is likely the future of most medical specialties, and, with cardiology’s role in invasive vascular and electric procedures, it is likely that further fusion will occur in the direction of surgery, neurology, and imaging.
Ultimately, we will need to focus on the skills that patients will require as a direct consequence of their disease biology if we are to be able to educate our trainees and ourselves strategically for the future. Cardiology’s core skills include invasive and integrative physiology, quantitative risk management, device implantation, and remote monitoring, among others. The fundamental basis of systems biology was established by engineers moving into cardiovascular physiology in the 1950s, and this tradition of quantitative applied science has driven innovation in areas such as catheter design, structural heart disease, valve prostheses, and percutaneous intervention ever since. Cardiologists are among the most technologically and digitally aware subspecialists in medicine. We have unique expertise with implantable devices, their management, and the acquisition and processing of continuous data streams and their analysis. In addition, we have developed expertise in dealing with the complications of implantable hardware. These paradigms are now being deployed in fields as diverse as drug delivery systems and remotely regulated cell therapy chambers. Training cardiologists to adapt more efficiently to emerging concepts and emerging technologies must be at the forefront of our educational programs.
Refocusing Professional Education
Central components of all medical education must continue to be the fundamental biology of the diseases that we treat and the fundamental nature of what it means to be a physician. Although efforts such as evidence-based medicine and guideline-based care have served to increase the uniformity with which care is delivered, there is an inherent tension between such tools and professionalism. In essence, if the care plan for a condition can be comprehensively implemented as an algorithm, then the management of that condition should largely devolve to nonprofessionals or ultimately to fully automated platforms. As innovation in personal technologies accelerates, the process by which such devolution takes place should also accelerate, leaving the medical provider to focus on those areas where professional insight is truly necessary. At the heart of professionalism is also the tension between tightly circumscribed duty hours and the open-ended commitment to solve fundamental problems for the patient. Although objective data are currently being collected on the effects of duty hours for cardiovascular fellows in training on patient care, reduced exposure to patients, and reduced exposure to the natural history of disease have had a major effect on the level of expertise of the trained cardiologist. There is no doubt that recent changes in training program structure have had substantive effects on work–life and service-education balance, but without similar efforts to redress the technical-professional balance, there will remain significant mismatch between expectations and reality for many fellows on the completion of their training. Shifting the educational burden to the early years of unsupervised practice immediately posttraining serves neither the patient nor the physician well and must be addressed as future iterations of training requirements evolve.
As knowledge generation and knowledge management, even within a circumscribed field such as cardiovascular medicine or surgery, rapidly exceed the capabilities of any single practitioner, training cardiologists in the techniques of data curation, data management and analysis, and real-time data application will become critical. The cardiologist of the future must be able to manage situations that they may never have seen through their ability to apply insights from vast data sets to the individual patient, leveraging novel data display technologies, deep understanding of the underlying technologies, and a rapidly growing armamentarium of therapeutic approaches. This reprofessionalization of medicine, focusing on the ability to use all extant knowledge (not just a limited set of evidence) to manage uncertainty in individual cases, requires much more extensive and multidisciplinary training than can be achieved in a time-defined apprenticeship. Similarly, it will require a sophisticated redesign of current assessment tools to capture the skills required to function independently in this new arena. Fortunately, the very technologies that are driving the ongoing revolution in cardiology can also be adapted to derive metrics by which innovation can be assessed.36
Clearly, this rebalancing would also require a return to training in investigative cardiology with a focus on discovery and the application of inference from first principles. These principles may seem like a return to a bygone age, but are very closely aligned with the concept of the learning health system. Quality care not only applies uniformly what is already known, but also builds systematically on this foundation.
The tension between professionalism and the need for a uniform minimum for professional education is present in every area of human endeavor. The failure to accommodate to new paradigms or to drive new insights to practice can lead to remarkable changes in the role of a profession. Although the analogy is not perfect, a reliance on the simple management of a proprietary knowledge base did not serve most travel agents or retail stockbrokers well as alternative technologies emerged. Finding innovative ways to educate cardiologists and to measure the outcomes that matter to society will itself be part of the current wave of change in the field. Ultimately, physicians are judged on their ability to affect disease course and outcome, and at the center of this evaluation must lie our ability to influence how our patients feel, and how long they live, as well. Technology and innovation must serve the patient-provider interaction, not hinder it. The conversion of the healer into a data entry clerk must be firmly resisted at every level in the profession, especially at the earliest stages of the educational journey.
Practical Solutions to Rapidly Changing Demands
The dynamic period outlined above is already upon us. Recent changes in the American Board of Internal Medicine requirements for maintenance of certification (MOC) led to a dramatic reappraisal of the goals and mechanisms of this process. The resulting political dynamic reflects the strains that new knowledge places on the provider, combined with decades of deprofessionalization and external competitive pressure. To overcome these challenges, the American Board of Internal Medicine is in the process of restructuring the instruments of education and assessment required for MOC.37,38 The details of this restructuring are not yet known, but doubtless will have direct practical implications for cardiology education in the next few years. Given the pace of change in our current educational environment, it is likely that the specific features of the remodeled MOC process will embody several emerging educational principles.
Primary cardiology education and MOC must deliver certain key requirements. Although implementation details may vary, the core values will remain unchanged from those of the pioneers in the field (see Table):
a continuously evolving and devolving minimal knowledge base;
a capacity for ongoing professional interpretation of data from first principles;
a minimal skill set ranging from the purely technical through to emotional skills,imparted through a combination of simulation and experience;
facility with adaptive learning systems;
continuous assessment of competence, ideally through federated data from the individual’s actual practice incorporating patient and other metrics;
regular reappraisal of traditional workflows to ensure minimization of human error. Accepted standards for workflow in particularly vulnerable areas of practice that are reviewed and remodeled on a regular basis. This process should be akin to the checklists used to refine and maintain airline safety, another highly complex field where the combination of technical improvements and efforts to minimize human error through standardization have dramatically improved outcomes. All this must be implemented in ways that retain the ability to respond to unanticipated challenges offered by a professional.
There are numerous ways in which each of these potential values might be realized, now or in the future. For example, one might imagine new clinical data delivery platforms capable not only of summarizing much larger data sets, but also of analyzing these in real time and using similar subjects in comparators. The basic data set may change over time, but there must be a premium on interpretative skills rather than rote learning. Gone are the days when one might be able to commit to memory all the required material for clinical practice. Simulation technologies continue to transform the safety of early patient encounters, and the ability to develop scenarios that include not only well-defined procedural skills, but also other teachable outcomes ranging from empathy to the management of the complex patient. Finding ways to teach and measure these skills and their maintenance throughout a changing career will be vital for professional integrity. Measuring performance will become more rigorous as we develop approaches to use digital transactional data (from the electronic health record and elsewhere) in combination with population metrics, patient-reported outcomes measures, and other federated data in addition to the traditional evaluative metrics. Patient outcomes will be included, but must use much more granular approaches to correct for case mix complexity. The profession must drive these measurement approaches from within. Longitudinal time series will allow the provider to detect subtle changes in performance and to pursue reeducation on a just-in-time basis rather than using fixed recertification periods. Even where educational metrics are continuously met, groupthink can persist, and in high-risk situations, best practices in retraining or workflow redesign, such as those adopted by airlines, have been shown to reduce systematic errors of omission. Similar efforts in cardiology might reduce the remarkable variation in areas indexed by metrics such as the time it takes to propagate definitive evidence for an intervention to the entire population. Regular realignment of workflow will also identify professional outliers whose practice patterns do not reflect the evolving norms. Fundamentally, a major challenge for cardiology education in the next 1 to 2 decades will be to maintain traditional professional standards, while still accommodating remarkable increases in the available technology, data, and therapeutic avenues.
Building the Teams of the Future
The physician has traditionally been a solo professional, and much of the identity and reputation of the physician is dependent on the ownership of responsibility for the patient’s well-being. Although the paramount value of a therapeutic physician-patient relationship is clear, new emphasis is already being placed on team-based care and, thus, team-based education. This teaming encompasses 2 general patterns: (1) devolution of algorithmic elements of care to an integrated team of nonphysician providers, pharmacists, navigators, and others, recognizing the different skill sets that must be organized to scale these types of interventions; and (2) the necessity for input from multiple superspecialists in highly complex cases where a wide range of different risks and benefits must be integrated for effective decision making and management. These different team structures can overlap, but require quite different skill sets, the majority of which are not taught in an organized way in current fellowship programs. The science of teams is relatively immature and its application to clinical care teams is recent at best. Nevertheless, if cardiology is to survive in an era of innovation, we must become more adept at teaming (building, leading, and participating in flexible teams), and we must develop formal approaches to educating our trainees in these skills. For example, many of the scenarios where robust algorithms can be developed are rapidly leaving the scope of medical practice largely because the profession has failed to adapt and build scalable solutions.
In some areas, such as cardiology intensive care or heart failure devices, cross-specialty training programs are being developed. Although these initiatives have great merit and may well be reasonable approaches for the short or intermediate term, it is difficult to imagine them as generalizable solutions given the rapid evolution of new technologies, new interventions, and new patterns of care, each in turn more complex. In other professions and other industries, matrixed cross-training has become the norm as the sophistication of skills necessary to solve specific problems has increased. The concept of flexible teams with discrete expertise and different roles coming together around individual problems is now commonplace in most technologically heavy fields. Medicine, in general, will have to develop strategies where one does not require 5 separate subspecialists to manage a single common process (eg, the metabolic syndrome and its complications), yet in highly complex critical care these same 5 subspecialists can efficiently come together to make timely decisions 24 hours a day. From the vantage point of history, there will likely always be a role for the integrating physician, and this may lead to a resurgence in the generalist team leader deeply expert in the longitudinal course of disease and closely connected with the patient and the patient’s wishes. This should continue to be the focus of cardiovascular medicine training programs, even as the scope of the role changes dramatically.
Given the incentives for team-based performance measurement, it is likely that in the future the assessment of competence will have to also include metrics of the physician’s competence in team building and team care. Essential to the success of these efforts will be evaluation of patient metrics at the individual and population level. How these competence metrics might be implemented remains unclear, but will likely involve objective and subjective assessments that are embedded in the technology infrastructure that these new models of care will demand. As outlined above, as the infrastructure used for clinical care and education becomes more integrated, it will become possible to imagine not only learning health records, but also truly adaptive education and MOC systems that will include not only the evolving knowledge base, but also the dynamic components of the team. These learning health systems will allow MOC to become truly continuous with regular in-line updates and assessments focused on the individual practitioner’s recent performance taking the place of episodic recertification.
Future of Cardiovascular Training for Cardiac Surgeons
Current training for cardiac surgeons to qualify for board certification is dictated by the American Board of Thoracic Surgery (ABTS). Founded in 1947, the ABTS previously required full-residency training in general surgery along with certification by the independent American Board of Surgery to be accepted into a thoracic surgery residency. This American Board of Surgery certification requirement determined the initial 4 or 5 years of surgical residency training for cardiothoracic surgeons. It was not until 2003 that the ABTS removed American Board of Surgery certification as a requirement for entering the ABTS certification process.39 Many thoracic surgery residency programs continue to select their residents from traditional general surgery programs, but, in the past decade, the integrated thoracic surgery residency program has been implemented at >20 thoracic surgery residency programs. In these newly integrated residency programs, applicants matriculate directly from medical school to 6 years of cardiothoracic residency. The first 3 years involve basic surgical science education along with exposure to cardiovascular, pulmonary, and critical care medicine, and selected surgical specialties such as vascular surgery. The remaining 3 years comprise adult and congenital heart surgery and general thoracic surgery training with schedules and educational experiences similar to the traditional 3-year thoracic surgery residency.
Even with the adoption by ABTS of this thoracic surgery-focused resident training curriculum, the current residency requirements for cardiac surgeons includes substantial clinical and surgical training experience in general thoracic surgery. There are minimum operative case requirements for pulmonary, esophageal, and other thoracic operations. In addition, in the examination process for ABTS certification, applicants must demonstrate competency in all areas of thoracic surgery. As stated on the ABTS website: “education and adequate operative experience in both general thoracic surgery and cardiovascular surgery are essential parts of any approved thoracic surgery residency program, irrespective of the area of thoracic surgery in which a candidate may choose to practice.”
When considering the future training paradigms for cardiac surgeons, it is reasonable to expect that the recent adoption by the ABTS of subspecialty training tracks will continue and become even more cardiovascular specific, reflecting what has occurred in Canada and Europe, where cardiac surgeons and general thoracic or chest surgeons will spend most of their training in their respective areas. ABTS reluctance to support further cardiac surgery–only training tracks is based on the assumption that many ABTS-certified surgeons in the United States perform both cardiac and general thoracic operative work. However, it is uncommon today at major cardiovascular centers for cardiac surgeons to perform general thoracic surgery or vice versa. It is more common to see cardiac and vascular surgeons working together in a heart and vascular center than for cardiac and general thoracic surgeons to be working together in thoracic surgery programs.
The current subspecialty training pathway established by the ABTS for congenital heart surgeons provides a template for future specialization training for adult cardiac surgeons. The Congenital Cardiac Surgery Subspecialty Certification program was instituted by the ABTS in 2009. The applicant surgeon must complete an ABTS-approved thoracic surgery residency before entering one of several accredited 1-year congenital heart surgery fellowships that are offered in the United States After successful completion of the fellowship, the surgeon is eligible for another round of written and oral certifying examinations administered by the ABTS and leading to subspecialty certification in congenital cardiac surgery.
It is widely accepted that cardiac surgery residents will require additional training following the traditional 7- or 8-year training track, even after an integrated 6-year residency program, if their intention is to practice in what have become de facto subspecialty areas of adult cardiac surgery. Such areas of special competence include advanced valve surgery such as aortic root reconstruction, complex mitral valve repair, and transcatheter valve replacement procedures. Surgery for patients with advanced heart failure includes heart transplantation, ventricular assist devices, and complex left ventricular reconstruction surgery, and is another subspecialty area in adult cardiac surgery that usually requires additional training for most cardiac surgery residents. With current operative case requirements required to qualify for ABTS certification and with limitations on residents’ operative training opportunities related to work-hour rules, residents rarely obtain adequate training in such subspecialty areas during the thoracic surgery residency. Another subspecialty focus is surgery of the thoracic aorta, which increasingly involves competence in endovascular grafting. Thoracic surgeons rarely obtain adequate experience in this challenging surgical area without additional focused training, often acquired in informal fellowship training experiences at cardiac surgery centers with large case volumes.
Other subspecialty areas that have emerged in cardiac surgery are minimal access surgical techniques, primarily for valve repair and more recently for coronary bypass grafting. Off-pump techniques for coronary bypass grafting procedures, and the use of robotic assistance for both valve and coronary bypass grafting operations, as well, also require additional training experience for the thoracic surgery resident. Also emerging is the hybrid cardiac surgeon, the individual who undertakes additional training in coronary artery and structural heart catheter procedures. Although the need for and advantages of a surgeon-catheter interventionalist remain to be demonstrated, some young cardiac surgeons are interested in obtaining this nontraditional skill set.
Subspecialty congenital cardiac surgery certification offered by the ABTS is unlikely to be available in other subspecialty areas of adult cardiac surgery because of the complexity of the certifying process and the relatively small number of cardiac surgery residents annually who would qualify for and seek such subspecialty certification. Although board certification generally is required for hospital privileges and to qualify for payments by insurers, basic ABTS certification is sufficient for most hospital credentialing committees to allow a surgeon to perform the full bundle of cardiac surgery procedures. It is uncommon for credentialing committees to restrict ABTS-certified surgeons from undertaking any cardiac operation. Board certification, however, does not ensure that a surgeon is safe and competent. Despite completing the required residency training with the approval of the program director, and despite passing both the written ABTS examination that assesses the candidate’s knowledge base and the oral examination that focuses on assessing surgical judgment, a surgeon’s competence once in independent practice cannot be assumed. The responsibility for protecting the public from a surgeon’s level of competence shifts from the certifying board to the hospital’s privileging committee that oversees the surgeon’s actual performance.
In the future, training for cardiovascular surgeons should mirror the ABTS subspecialty certification process for congenital heart surgery. Fellowship pathways for acquiring appropriate training in adult cardiac subspecialty areas both for thoracic surgery resident finishing ABTS programs and practicing cardiac surgeon whose goal is acquiring new skills and competence will continue to rely on varied and less formal training schemes that will likely continue to be outside the regulatory scope of the ABTS. However, we increasingly find ourselves as cardiovascular physicians and surgeons functioning in a clinical environment that is defined more by the illnesses and diseases of the patients we are caring for than by the traditional structures of academic departments and specialty boards. We work in institutes and service lines rather than departments in many institutions. There are many cardiac surgical procedures and areas of practice that overlap with or require active engagement of other specialists: transcatheter aortic valve replacement with interventional cardiologists and echocardiographers, repair of thoracoabdominal aortic aneurysms with vascular surgeons, management of ventricular failure with both heart failure and interventional cardiologists. The Heart Team concept for optimal patient care should become an important component of future cardiac surgery training programs, especially in emerging and evolving treatment areas. Experiences in the cardiac catheterization and imaging laboratories are a component of the integrated cardiothoracic surgery residencies. Similar cross-specialty training experiences in emerging adult cardiac surgery subspecialty areas should be embedded in these training fellowships.
The scope of practice in cardiac surgery has evolved because of the development of new surgical procedures, techniques, devices, and treatment strategies. Regardless of the completeness of cardiac surgery resident training at any given time, new and different clinical and surgical skills will be necessary for surgeons to acquire over time. Despite the aspirations of the ACGME and the specialty boards to have board recertification or MOC processes to ensure appropriate physician and surgeon practice, training up to match current standards for cardiovascular practice is left to practitioners themselves with some de facto oversight by hospital credentialing committees. The unique partnership involving the Society of Thoracic Surgeons, the American College of Cardiology, and the Centers for Medicare and Medicaid Services for credentialing of transcatheter aortic valve replacement centers of excellence demonstrates another model for defining the quality of on-going cardiovascular training in new therapies.40 There are other encouraging examples of self-governing initiatives in cardiovascular medicine such as the emergence of Appropriate Use Criteria both for diagnostic testing and treatment41,42 that could be extended to cardiovascular training, ie, the Society of Thoracic Surgeons and the American College of Cardiology plus American Heart Association developing Appropriate Training Criteria for advanced heart failure treatment; and the Society for Vascular Surgery and the American Association for Thoracic Surgery partnering on training and treatment guidelines for thoracoaortic aneurysms.
Future training for cardiovascular surgeons will continue to evolve but within the purview of the ABTS which will continue to certify for the public the adequacy of the basic training and competence of cardiac surgeons. Through its MOC program, the board also will demand evidence of on-going education and professional competence. As the role of the cardiac surgeon evolves as a result of new procedures, techniques, and devices, the surgeon’s training needs will be increasingly defined by the Heart Team principles that have been described so well in the past decade.43
There will be even more subspecialty tracking in thoracic surgery training programs as currently is seen in Europe. There will be continued individualized intensive cardiac surgeon training in subspecialty areas. We also can expect even greater collaboration among procedural cardiovascular specialists, cardiac surgeons, cardiologists, vascular surgeons, noninvasive imaging cardiologists, vascular interventional radiologists, and others. The training requirements mandated by the ABTS will ensure the basic cognitive and procedural skills expected of all cardiac surgeons. Additional training in a wide array of individualized programs, occurring in a collaborative setting that includes nonsurgeon cardiovascular experts, will ensure that cardiac surgeons continue to advance cardiovascular care into the future.
The future we have set out must overcome several fundamental challenges that have always existed in professional medical training, but which, because of the net effects of growing complexity in cardiovascular practice, a rational desire for rigorous minimum standards, the lack of any meaningful competition, and the current medicolegal environment, have led to systematic deprofessionalization during training. If we are to move beyond our current need to legislate for every conceivable event to a future where we can efficiently adapt in real time, we will have to define new approaches to generating knowledge and managing it as it emerges. This will require working collaboratively with others to ensure that we serve the full interests of the patient and that we regulate each other’s performance. This direct return to the qualities that defined the transition from patronage to professionalism in the Middle Ages also requires letting go of areas of prior influence that no longer merit professional inquiry. To meet all these goals will require building new infrastructure for learning and assessment, ideally embedded in the informatic tools that are the basis for modern clinical practice. The greatest challenge may be maintaining the human components of medical training, but with the appropriate long-term goals, technology can be deployed to liberate trainees and trainers alike to develop the bonds that first made our profession so attractive to inquiring minds.
- © 2016 American Heart Association, Inc.
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