Does congenital cardiac surgery training need a makeover?

Key clinical point: Since congenital cardiac fellowship programs became accredited in 2007, training requirements have been standardized and the surgical experience robust.

Major finding: Recent graduates of fellowship programs are thriving in practice, but shortcomings with existing fellowship training exist, including only 50% gaining certification by passing the written and oral exams.

Data source: The study drew on survey responses from 36 of 44 fellows in 12 accredited programs and a review of operative logs of 38 of the 44 fellows.

Disclosures: Dr. Kogon and his study coauthors had no financial disclosures.

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Despite accreditation, some shortcomings exist

In his invited commentary, Dr. Charles D. Fraser Jr. of Texas Children’s Hospital, Baylor University, Houston, called the study findings that only 50% of congenital cardiac surgery fellowship graduates had passed the congenital examination “quite disturbing” and the demographic data and surgical and nonsurgical experience of the trainees “thought provoking” (J Thorac Cardiovasc Surg. 2016;151:1496-7)

“Is the bar too high or too low?” Dr. Fraser asked. He suggested the fellowship training system for congenital cardiac surgeons may be a work in progress. “For one, having a median age of 40 years for graduates is unacceptable,” he said. For half of trainees to not pass the examination “at this advanced age is tragic.” That 25% of fellows participate in nonsurgical rotations “also is concerning.”

Dr. Charles D. Fraser

A challenge is that after fellows complete their training in general and cardiothoracic surgery, opportunities to operate on newborns in a new fellowship setting are extremely limited, Dr. Fraser said. “To expect someone to be able to perform complex newborn heart surgery with excellent outcomes in a brand-new environment after just learning how to perform adult cardiac surgery is unrealistic,” he said.

Dr. Fraser said 1 formal year of training for congenital cardiac surgery fellows may not be enough. “Our colleagues in general pediatric surgery have a 2-year fellowship, and our specialty is every bit as complex as theirs,” he said. The basic American Board of Thoracic Surgery thoracic fellowship should have more latitude in its congenital heart surgery rotations, including exposure to pediatrics, neonatal/pediatric critical care, and the nonsurgical rotations the study referred to. Congenital heart surgery fellowships should also embrace adult congenital heart surgery with a more formalized experience requirement, he said.

“As a specialty, we owe it to our fine young surgeon candidates to offer the most robust and fair pathway to success while never compromising on the public trust and patient well-being,” Dr. Fraser said.

Dr. Fraser is chief of the division of congenital heart surgery at Baylor and codirector of the Texas Children’s Heart Center. He had no financial relationships to disclose.



Trainees in congenital cardiac surgery fellowship programs are doing more operations since the programs became accredited in 2007, but no clear parameters have emerged to determine if certification has improved the quality of training, according to an evaluation of fellowship training programs published in the June issue of the Journal of Thoracic and Cardiovascular Surgery (2016 Jun;151:1488-95).

Overall, the training has become standardized, the fellows’ operative experience is “robust,” and fellows are mostly satisfied since the Accreditation Council of Graduate Medical Education (ACGME) recognized congenital cardiac surgery as a fellowship in 2007, lead study author Dr. Brian Kogon of Emory University, Atlanta, said.

However, Dr. Kogon and his colleagues also found some shortcomings in fellowship training. They received survey responses from 36 of 44 fellows in 12 accredited programs nationwide. To determine if fellows were meeting minimum case requirements, they also reviewed operative logs of 38 of the 44 fellows. They compared their findings to a study of congenital cardiac surgery fellowship programs they did pre-ACGME accreditation (J Thorac Cardiovasc Surg. 2006 Dec;132:1280). “The number of operations performed by the fellows during their training was underwhelming, and most of the fellows were dissatisfied with their operative experience,” Dr. Kogon and his colleagues wrote in the earlier study.

The study found that all fellows achieved the minimum number of 75 total cases the standards require for graduation, with a median of 136; and the minimum standard of 36 specific qualifying cases with a median of 63. However, seven did not meet the minimum of five complex neonate cases. Among other types of operations for which fellows failed to meet the minimum cases were atrioventricular septal defect repair, arch reconstruction including coarctation procedures and systemic-to-pulmonary artery shunt procedures.

The comparative lack of adult cardiac surgery operations was also considered a potential problem, the authors noted, pointing out that “the number of adults who have congenital heart disease now exceeds the number of children who have the disease, and many of these patients will require an operation.”

Another shortcoming the study found was a drop-off in international fellowships since 2007. “This change places us at risk of becoming intellectually isolated and losing international relationships that are critical to the future of our specialty,” Dr. Kogon and his colleagues wrote. Graduated fellows also acknowledged dissatisfaction with their lack of exposure to neonate surgery.

The study also determined the following demographics of the fellows: 83% are men and the median age at graduation was 40 years, with a range of 35-48 years. Only 25% of graduates participated in nonsurgical rotations such as cardiac catheterization and echocardiography.

“Although the operative experience seems to be much more robust, and this finding has been corroborated in other surgical disciplines after the advent of ACGME accreditation, comparing training before and after the accreditation process came into existence is difficult,” Dr. Kogon and his colleagues said.

The study also noted that the Thoracic Surgery Directors Association developed a congenital curriculum for congenital cardiothoracic surgery fellows, but only 28% used that curriculum and only 61% used any formal curriculum. “Unfortunately, regardless of the curriculum, only 50% of the graduates found it helpful,” Dr. Kogon and his colleagues said.

And regardless of the curriculum, only half of the graduates have passed the written qualifying and oral certifying examinations after completing their fellowship. “Although the curriculum is quite robust, the latter statistic suggests that we need either more emphasis on education by the program directors or a better and/or different curriculum,” Dr. Kogon and his colleagues said. However, they added that “after training, former fellows have adequate case volumes and mixes and seem to be thriving in the field.”

Dr. Kogon and his study coauthors had no financial disclosures.

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