Countries with no training facilities

Iceland and Cyprus are limited in population which makes it difficult for them to develop or sustain a training programme. Many cardiologists in smaller countries face challenges in achieving recognition of their speciality, providing comprehensive care and all the subspecialist components (electrophysiology, heart failure/transplantation/pulmonary hypertension, advanced imaging) in addition to achieving cardiac surgical outcomes comparable to large international centres.

Furthermore, limited access to a critical volume of patients, with significant disease severity, lack of a formal curriculum, high-quality instructional design, and most importantly time to train fellows may all prove barriers to effective training practices. Even once a training programme has been established, a need for regular standardised assessments, exit examination, and certification may prove a problem for smaller countries. It takes a significant amount of time and effort to construct an exit examination, which makes it unrealistic for small or even larger countries to individually develop this especially when one considers the small number of graduates in each country each year, for example the United Kingdom may only have 15–20 trainees graduating each year. Limited financial resources (gross domestic product) may also play a significant factor in limiting development of paediatric cardiology training (Table 2 and Fig 5).

Common problems in training

Several delegates reported many positive aspects of training in European centres (Table 7). Trainees themselves have previously reported high satisfaction with overall training from countries with well-established programmes. ^{Reference Horst, Michel, Kubicki, Lang, Zschirnt and Moosmann22} However, it is clear that there is also room for improvement. One of the most cited problems in training was limited trainer time availability (Table 7). Many cardiologists are extremely busy providing clinical services, even with a median number of 4.2 cardiologists per million population. There is also a very wide disparity of resources in terms of the European paediatric cardiology workforce with a range of 0.9–11.8 cardiologists per million population. In the United States, there are 2860 paediatric cardiologists which represents 8.8 per million population. ^{Reference Mehta, Fisher and Rzeszut23} It is not surprising that teaching and training may be at the bottom of the priority list in such under-resourced and challenging settings. Furthermore, one can surmise that limited investment in fragile public health services over the last few decades, ^{Reference Mackenbach, Stirbu and Roskam24,25} highlighted in many countries by the current COVID-19 pandemic, may have compromised our European wide capacity for future training and evolution of paediatric cardiology and indeed wider medical services. Differences between privately and state-funded healthcare provision may also significantly impact upon the availability of training, location of training, and indeed career outcomes of trainees.

Other weaknesses reported included too few fellows in the programme, lack of formalised training structure (teaching/assessment), ^{Reference Horst, Michel, Kubicki, Lang, Zschirnt and Moosmann22} lack of standardisation of subspecialist services, smaller centres with limited capacity to deliver all subspecialist services, and lack of local access to a cardiac morphology course. The latter is more recently becoming more readily achievable remotely as well as via the excellent “in person” courses run in the United Kingdom (Great Ormond Street Hospital, Royal Brompton & Harefield hospitals (rbt.nhs.uk) and via the online Heart Academy (cardiacmorphology.com)). The lack of access to all subspecialist services is a challenge for smaller countries (e.g. electrophysiology training is a much bigger challenge on both small and large countries alike). Some have also questioned how subspecialised training should be, given that many paediatric cardiologists will spend much of their time in an outpatient setting, and not more subspecialised settings. ^{Reference Moodie26} This does however beg the question that the outpatient setting in some ways requires the highest level of specialisation; the need to acquire and maintain the most current and ongoing knowledge of all treatment modalities available for patients, for conditions where optimisation of timing for optimal intervention or reintervention is crucial. Balancing these needs is difficult.

Comparison with North American training

Training in North America is generally well organised to a high standard with a standardised curriculum accepted by most programmes. There are 60 paediatric cardiology fellowship programmes in the United States (https://www.nrmp.org/fellowship-match-data/). Core training is 3 years with the option of completing a fourth year in advanced training. Most cardiac programmes have a dedicated fellowship director who meets regularly with trainees and monitors their progress in reaching the six competencies promoted by the Accreditation Council for Graduate Medical Education. Europe could adopt a similar curriculum and structured core programme of 3 years with the option of a fourth subspecialisation year.

The European Working Time Directive has also impacted the need for a longer duration of training in European countries to meet the competencies required for satisfactory completion of training compared to a what was previously a more intensive shorter period of training in the United States. However, between 2004 and 2015 the number of United States paediatric cardiology fellow positions increased from 61 to 141, primarily to take account of the implementation of work hour restrictions there also. ^{Reference Ross, Srivastava and Cabrera27}

One of the challenges for European programmes is significant resource limitation especially in terms of “teaching faculty”. Medium-sized North American programmes often have 20–30 members on their faculty while larger programmes (Houston, Boston) may have in excess of 60–70 faculty members, with a dedicated fellowship director who has often received formal educationalist training. This enables faculty members to spend greater time training and also undertaking fellow assessments. Increased resources, often a challenge for smaller European centres, in terms of faculty and educationalist training are critical to implementing an effective training framework. Medical systems in Europe often differ radically to those in the United States where institutions and departments may be remunerated for patient care, whereas a public healthcare system is employed in most European centres. These stark differences in training infrastructure may pose practical dilemmas for trainees embarking upon their careers. Where there is a real or even perceived lack of “parity of esteem” between European and North American centres, trainees may feel their chance of securing a consultant position is greater if they spend 3–4 years training in a North American centre compared to a comparable European centre, where the training may be as long as 5 years of duration. We must ask ourselves the question is it fair to ask our trainees to train for longer in a programme with less resources to be less competitive than a comparable trainee who spends less time training in a better-resourced international centre?

Another notable difference between North American and European programmes is the dedicated time apportioned to research. The Accreditation Council for Graduate Medical Education mandates that 12 months of the 3-year United States programme be devoted to research (typically towards the latter part of the programme) while the majority of European programmes had no dedicated time or relatively limited time specifically for research without taking time out of training (Table 4). This may be partly accounted for by the larger numbers of fellows in North American programmes (some exceeding 20 fellows per programme) and the fact that highly reputable programmes often attract international research fellows, some of whom provide their own funding. There are very few European programmes with such high numbers of fellows so service provision and patient care may be the primary focus in those less well-resourced centres.

Realistically, every trainee cannot go to North America to train as not only are there limited training positions and challenges in meeting entry criteria (United States Medical Licensing Examinations) but also because they would be returning to a very different healthcare system. More recently, completion of a paediatric residency in the United States is also required prior to starting fellowship training, potentially requiring experienced trainees having to repeat general paediatric training. Furthermore, not every European country may recognise United States Board certification qualifications for entry onto the specialist register (e.g. United Kingdom) even when they are secured.

To address some of these challenges in training, the educational committee of the Association for European Paediatric and Congenital Cardiology was established. The committee is composed of several members from multiple different European countries with broad levels of experience and expertise, includes a junior representative, and has adopted a very active role in developing guidelines for general paediatric cardiology and individual subspeciality training (published by working groups) in addition to the development of a logbook. ^{Reference Kriebel, Rosenthal and Gebauer10–Reference Moons, Bratt and De Backer16} It is currently in the process of establishing a European exit examination which could be recognised across all countries (AEPC certificate). The European Association of Cardiovascular Imaging echocardiogram examination has been a very successful benchmark model examination. A comparable knowledge-based examination although a challenge to develop could prove a useful development.

Should all training be in surgical centres?

Across Europe, there are some major teaching hospitals that have some specialised paediatric cardiology inpatient services but without surgery or interventional cardiology on site. The overall complexity and intensity of CHD case exposure at surgical centres generally exceeds that at the non-surgical cardiology centres. Consequently, we would advocate for trainees to be able to spend the majority of their time in surgical centres so as to receive exposure to complex cardiac physiology and be involved in the post-operative management of patients but fully acknowledge that there can be significant benefit from rotations that include time in non-surgical centres as well, for example, in the Irish training scheme trainees rotate through the Dublin surgical centre for the majority of their training but also rotate through Belfast where there is benefit from the well-established cardiology service and strong research aspects of training as well. Even though many countries surgical centres function as their main training centres (Table 1), there is also likely benefit from rotations even between major surgical centres as learning can be gained from “more than one master”. In countries with none or very limited surgical programmes, the potential for trainees to rotate through other surgical centres in other countries would be important.

Adult CHD training

To date, there is no uniformity of provision of adult CHD training across Europe. Many of the problems are similar to those for paediatric cardiology. On the one hand, many paediatric cardiologists have grown older together with their patients and have continued to care for them. These paediatric cardiologists have usually been trained in adult CHD because of their ongoing clinical practice. On the other hand, adult cardiologists have also begun to focus on the care of adolescents and adults with CHD. With their internist background, they lean more towards adult care and have more training and experience in both acquired heart disease and the wider diseases of ageing. For more than 20–30 years, they have been proficient in the care of adult CHD patients through a more practice-based approach. Both type of specialists can be considered as “made by the job.”

Meanwhile, the number of patients with CHDs reaching adulthood has steadily increased, so that more adult CHD healthcare providers are gradually required. ^{Reference Baumgartner28} Expert centres worldwide which had already developed a well-structured adult CHD programme opened the doors for training paediatric cardiologists and adult cardiologists to become fully fledged adult CHD specialists. Many adult CHD specialists undertook clinical training in the United Kingdom or outside Europe. In the meantime, several expert centres have emerged on European soil which can offer full-fledged training to adult CHD specialists. ^{Reference Baumgartner, Budts and Chessa29} It goes without saying that as the need to align training courses grew, thought was given to the minimum content of clinical training to become an adult CHD specialist. Few recommendation papers for general and more specific training in the adult CHD subspeciality were published over last decade. ^{Reference Baumgartner, Budts and Chessa29–Reference Chessa, Baumgartner and Michel-Behnke32}

As a result, a European certification for adult CHD specialists is also currently being considered. Certification would likely entail passing a theoretical exam and would also require a minimum of clinical exposure. It is unclear how best this should be considered at present, but the best candidates to undertake this may be European scientific societies already responsible for training and research. How this European certificate could be introduced in the different countries is included as reflection. Few countries currently require an examination or certification to practice adult CHD (Table 6). Although the majority of adult CHD consultants surveyed believed European certification would help to standardise training, the marked heterogeneity (gross domestic product, healthcare organisation, health insurance, organisation of teaching, and education) across European countries may well pose a challenge for regulation and standardisation of training.

Proposed solutions

The findings from this study highlight the continuing question of how we can improve training support for countries with limited resources. We propose the following initiatives:

• To support colleague countries in applying to their Ministry of Health for formal recognition of subspeciality status of paediatric cardiology and adult CHD as independent specialities. This recognition is fundamental to providing a framework for training. In some countries limited gross domestic product may dramatically impact development of medical services including paediatric and adult congenital cardiology and funding streams may need to be developed to enable greater training and service development for such disadvantaged countries.

• To standardise the curriculum across different European countries, respecting there may be some specific competencies required in individual population groups.

• To increase awareness of competency and “capability” based medical education (much of the Shape of Training, United Kingdom ^{Reference McMahon, Tretter and Redington1} ). This provides a useful model framework which is important to ensure trainees are capable in each of the competencies they require. ^{Reference McMahon, Tretter and Redington1,Reference Narang, Velagapudi and Rajagopalan33}

• To establish and standardise formal fellowship training with recommendations for standard fellowship duration (3–5 years), rotations, and expected levels of entrustment and capability. We should ensure there is a focus on high-quality training and not simply counting the numbers of echocardiograms, catheters, electrophysiology studies, outpatient clinics which should be completed during training. The logbook could record the quality as well as the number of studies performed by the trainee. Recognising levels of entrustment to undertake “only under supervision,” “with limited supervision,” or “unsupervised” provides an excellent model.

• Most countries can offer basic level fellowship training (years 1–3). It is a credit to the speciality that much progress has been made in training subspecialists (e.g. electrophysiology, foetal cardiology and cardiac catheterisation). However, the vast majority of European cardiologists will spend most of their time looking after undifferentiated patients outside their area of special interest, either in the outpatient clinic, while on service or on call. It is critical that trainees are thoroughly grounded in “basic” or general paediatric cardiology so they can safely treat common paediatric cardiology problems. ^{Reference Shkolnikova, Osokina and Abdulatipova34}

• Encourage streamlining of advanced training (fourth or fifth year training) to larger centres for advanced imaging, catheterisation, electrophysiology, heart failure/transplantation/pulmonary hypertension. By concentrating resources on advanced training to high-volume/high complexity European cities/centres this may obviate the need to train in United States/Canadian centres, although that remains within the prerogative of the trainee. Many current trainees already travel to North America or a major European centre.

• Develop partnerships between countries with limited training support and larger better resourced countries with a track record in training congenital cardiologists. Although there may be language and logistical barriers to overcome this would appear to be a viable solution to such a heterogenous collection of countries. Potential collaborations/hubs of training, some already partially established, could be established between different countries, for example Norway, Sweden, Finland, Denmark and Iceland each with populations between 0.3–10 million could form a Nordic block (cumulative population >27 million) for training in both basic paediatric cardiology but also subspecialist training. Alternatively trainees from smaller countries with limited resources may benefit from an exchange programme undertaking elective periods (comparable to the Erasmus scholarship) at larger better resourced centres to supplement their training.

• The Association for European Paediatric and Congenital Cardiology as a governing structure is in a unique position to foster the birth, growth and development of such partnerships. Traditionally many trainees move to a handful of European centres (London, Paris, Rome, Milan, Berlin, Prague) or to United States/Canadian/Australian centres (Houston, Boston, Cincinnati, Philadelphia, Toronto, Edmonton, Melbourne) for advanced subspecialist training but it may be feasible that there is an equitable distribution of trainees around different European centres.

• Provide a common exit knowledge-based assessment, currently under preparation, which would lead to European Board Certification qualification. This could be standardised which would facilitate transfer of professional qualifications across different European countries. In addition, certification should focus on quality and competencies rather than purely on numbers of procedures performed/attended. Entrustable professional activities are also an effective means of bridging the gap between competency frameworks and clinical practice and will likely increasingly become incorporated into trainee assessment and certification. ^{Reference Ten Cate35}

• Develop and expand formal adult CHD fellowships across a greater number of countries given the current critical need to train adult congenital cardiologists to care for these patients. There is clear support among a majority of surveyed practitioners for introduction of a certification process for adult CHD training.

• The Association for European Paediatric and Congenital Cardiology education group can offer educational courses to educate trainers in instructional design and novel learning techniques (e.g. problem-based learning and simulation). The European Society Cardiology also advocates for training by hosting the CHD echocardiography certification examination (European Association of Cardiovascular Imaging).

• Encourage utilisation of novel pedagogical strategies including online learning, for example webinars (“Heart University,” “Congenital Heart Academy,” and “World University for Paediatric and Congenital Heart Surgery”). COVID-19 has shown us that there are many new ways to deliver very high-quality training; virtual delivery of some parts of the fellowship training series online and greater subspeciality virtual meetings can be leveraged to benefit European but also a wider global trainee audience, while remaining cognisant of the webinar fatigue which can arise from overexposure to these technologies. ^{Reference McMahon, Tretter and Redington1,Reference Tretter, Windram and Faulkner36–Reference McMahon, Tretter, Faulkner, Krishna Kumar, Redington and Windram38}

• The Association for European Paediatric and Congenital Cardiology can also advocate for educational sessions at research meetings including the annual meeting. There are already some exceptional educational courses (London morphology courses, Association for European Paediatric and Congenital Cardiology working group courses) which could be replicated and extended to different subspecialities. Morphology is the bedrock of paediatric cardiology: many national delegates emphasised that attending a recognised course should be mandatory for all trainees.

• Support ongoing research into the medical education of congenital cardiologists will assist in improving education and training for all our trainees. Funding sources (national and European wide) should be sought to invest in the education and training of congenital heart specialists.

These proposals outlined to provide greater consistency in training are purely that, proposals, and will require ongoing dialogue and planning among several countries under the Association for European Paediatric and Congenital Cardiology framework. This paper is only as useful as the tangible measurable real-life benefits accrued to our trainees and by extrapolation to our patients. Change is frequently difficult and often slow. The real work begins now and over the coming years to bring these proposals to fruition: we hope this opportunity is not squandered. While standardisation tends to improve overall standards of training, we recognise within individual countries there may be conditions that require specific training to care for the local population. ^{Reference McMahon, Tretter and Redington1} We welcome input from Association for European Paediatric and Congenital Cardiology affiliated countries who could not avail of the opportunity, at this time, to participate in this study. We look forward to collaborating with countries to improve training and education for congenital cardiologists.

Limitations

Despite persistent efforts to enrol all countries in this study, some countries’ national delegates could not be reached. Of the national delegates who responded, not every delegate was able to furnish a complete data set for all the variables we studied, due in part to the high variation of training delivery in some countries. We relied on each national delegate providing accurate data related to their country. To ensure data accuracy, we requested the national delegate from each country to review the finalised paper very carefully for potential inaccuracies. Although countries with a formal accredited fellowship are easy to identify, the differentiation between informal but substantive training can prove a challenge and there are nuances in training in specific countries. Characterisation of training did not always fall into a “neat box.” Where this existed, we quoted the national delegates to maintain accuracy and clarity in reporting. The assignment of “formal” or “informal” training is not meant to denigrate training in certain countries but to accurately reflect whether training is nationally recognised, with established exit examination and certification. We apologise if the use of such terms appears pejorative but that was not the intention. The ratio of paediatric cardiologist per million population may have slightly over or underestimated this ratio as the definition of one whole time equivalent paediatric cardiologist may vary from country to country. Small private practice institutions were not included in this study. Furthermore, the exact definition of a “paediatric cardiologist” may vary subtly between countries: we aimed to include only those who had completed paediatric cardiology training and practised actively as a paediatric cardiology specialist. Development of research competency is a critical part of training fellows (representing up to 12 months of the 36 month North American fellowship), and complete data from all European countries were not available. Further detailed work on adult CHD training will provide further insights into the needs of these trainees.