Definitions

Association for European Paediatric and Congenital Cardiology training centres are registered on the website and are defined as centres capable of providing the core training to enable fellows to reach competency/capability to work as an independent paediatric cardiologist.

Competency-based medical education encapsulates education which focuses on fulfilling critical competencies the trainee must acquire to meet the healthcare needs of their patients (e.g. the Canadian Medical Education Directive for Specialists (CanMEDS) roles of medical expert, communicator, collaborator, leader, health advocate, scholar, and professional). ^{Reference Pritchard, Alavian, Soogoor, Bartels and Hall24}

Education relates to gaining theoretical knowledge relevant to a specific field.

Training relates to the action of learning practical skills, acquiring knowledge and experience.

Entrustment assessment combines the evaluation of learners’ knowledge, skills, and behaviours with the evaluation of their readiness to be entrusted to perform critical patient care responsibilities.

Trainer is a paediatric cardiologist with the responsibility of educating and training paediatric cardiology trainees.

Trainee is a postgraduate doctor in training to become a qualified paediatric cardiologist, usually but not always on a defined accredited training scheme.

Workplace-based assessments assess a trainee’s professional skills and attitude and provide evidence of appropriate everyday clinical competences. ^{Reference Martin, Blissett and Johnston25} It has high content validity through assessing actual performance in the workplace. Workplace-based assessments are promoted as an integral part of curriculum design and educational planning, in which teaching, learning, assessment, and feedback are closely integrated. Workplace-based assessments include the following:

Multisource feedback (MSF) is a method of obtaining feedback in a structured form from staff associated with the trainee who have the opportunity to observe their practice. ^{Reference Brinkman, Geraghty and Lanphear26}

Summative feedback is provided at the end of the learning process and serves to provide trainees with an overall assessment of their learning, often with an associated grade.

Formative feedback typically contains ungraded or low-stakes opportunities to measure trainee knowledge and skills. Formative feedback is ongoing and helps trainers to focus on trainee learning and trainees to better understand the limits of their own knowledge and how to improve.

Entrustable Professional Activities are key tasks of a speciality or subspeciality, that a trainee can be trusted to perform, once sufficient competence has been demonstrated. ^{Reference Ten Cate, Chen, Hoff, Peters, Bok and van der Schaaf27–Reference Ten Cate and Schumacher29}

Questionnaire circulation

The survey was then circulated via email to the head of each training centre or a responsible trainer in all 95 Association for European Paediatric and Congenital Cardiology-affiliated training centres, and failing a response, a repeat email was circulated one month later. After a period of 4 months and multiple efforts to enrol centres, the training centre and trainer were deemed uncontactable.

Training received by trainers

Thirty-one trainers (67%) received some training in being a trainer, and 15 trainers (33%) reported receiving no training. There was a wide range of training received most commonly as a course by a local governing college for 22 trainers (47%), a certificate in medical education for 13 trainers (28%), a Diploma for 5 (11%), Masters in Medical Education for 6 (13%), and PhD in Medical Education for 5 trainers (11%). Training was provided by a university for 25 trainers (54%), a local hospital for 15 trainers (33%), a private certified education company for 3 trainers (7%), and the Royal College of Physicians, supervising body or self-sought private education centre for 2 trainers each (4%) (Figure 2 (a) and (b)). Thirty trainers (65%) believed this training made them better trainers (Figure 3). Thirty-three trainers (72%) believed themselves to be well qualified to train. Furthermore, 33 trainers (72%) disagreed or strongly disagreed with the statement “one does not need any formal training to train cardiology trainees” (Figure 4).

Figure 2.

( a ) and ( b ) Type and source of training received by trainers across Europe.

Figure 3.

Trainer self-perception of their qualifications to train.

Figure 4.

Trainer perception of need for formal training.

Instructional techniques and assessment tools

Taking the patient´s history and clinical investigation are important skills to be covered in the training of fellows. All trainers believe the history and physical examination to be a critical part of investigating the patient: 86% strongly agree, and 14% agree. Forty-five trainers (98%) disagreed (76% strongly disagreed, 22% disagreed) with the statement that “the history and physical examination are made redundant in the presence of imaging technology (echocardiography, MRI or cardiac catheterisation)”.

Assessment of trainees varies from daily to monthly between centres: in 17 cases (37%), the assessment was done every 6 or 12 months. Assessment tools used by trainers are shown in Figure 5.

Figure 5.

Assessment tools employed by trainers.

Trainer comprehension of different educational instruments and terms varied significantly and is provided in Table 1. Workplace assessments are used by 42 trainers (91%) as the most common type of assessment. Case-based discussions are used by 42 trainers (91%), mini-clinical evaluation exercise (mini-CEX) by 14 (30%) and directly observed procedures by 42 trainers (91%). Objective structured clinical examinations were used by 13 trainers (28%).

Table 1.

Comprehension of educational terms and instructional techniques among 46 trainers from 20 european countries

Entrustable professional activities were used in 12 training programmes (26%). Nine of these 12 centres (75%) used entrustable professional activities across all subspeciality areas (clinical examination, imaging, catheterisation, electrophysiology, and intensive care), while they were used in selective subspecialities (imaging or catheterisation) in 3 of 12 centres (25%). Eight of 12 centres (67%) which use entrustable professional activities reported the significant time component spent completing them as a major challenge. The advantages and disadvantages of entrustable professional activities are presented in Table 2. The benefits of entrustable professional activities were clearly outlined by trainers:

Furthermore, the clarification on readiness to progress was highlighted in addition to the apprenticeship style of training:

Time constraints on trainers to complete entrustable professional activities was by far the greatest disadvantage:

Table 2.

Advantages and disadvantages of entrustable professional activities expressed by 12 trainers currently using EPAs

Data presented as number of trainers (% of total using EPAs).

Our data showed that increasingly trainers are adopting their use, with eleven trainers (31%) in the process of implementing entrustable professional activities into their assessment portfolio.

Trainer feedback to trainees

Feedback was provided by 45 trainers (98%) to their trainees, most commonly formative feedback. Frequency of formalised feedback was monthly in 12 centres (26%), quarterly in 11 centres (24%), every 6 months in 9 centres (20%), and annually in 8 centres (17%). Many centres provide daily in the moment feedback on performance of diagnostic imaging or interventional procedures.

Trainer perceived weaknesses of training programmes

Strengths and weaknesses expressed by trainers are presented in Table 3. Lack of time to provide training was reported as the greatest challenge by 54% of trainers. The majority of trainers expressed a need for formal “training the trainers” courses and development of standards in training. Some of the open-ended responses from trainers included challenges with time constraints

Motivation was expressed as a challenge in

Dealing with the marked variation in trainee aptitude and knowledge:

At the other part of the spectrum:

Furthermore, lack of formal recognition of paediatric and congenital cardiology as a subspeciality was voiced as a problem by several trainers:

Table 3.

Trainer perceived strengths and weaknesses of their training programmes

Data presented as number of trainers (%).

Trainer perceived strengths of training programmes

It is important to point out that many centres are excelling in training:

Reciprocity of benefit between trainer and trainee was a well-recognised strength:

Several centres reported a very safe and fostering culture to allow trainees flourish in their training programme:

Time allocation and trainer recognition

Twenty-five trainers (54%) stated they had inadequate time for training trainees (Table 3). Twenty-three trainers (50%) disagreed or were neutral when asked whether they had dedicated time apportioned for training during the week. When asked whether their institution recognised (administratively, dedicated time allocation or financially) their work as a trainer, there was a wide variation in responses with 20 trainers agreeing (43%), 10 neutral (22%), and 16 disagreeing (35%). When asked whether their peers recognised their training efforts, 41 trainers (89%) agreed or were neutral in their response. Thirty-nine trainers (85%) reported their trainees recognised their efforts in training.

Continuous professional development as a trainer

Twenty-seven trainers (59%) attended courses or workshops for education in the preceding 18 months. Twenty-two trainers (48%) attended educational conferences or seminars. Seven (15%) undertook a degree programme in medical education. Twenty-two (48%) participated in individual or collaborative research related to medical education/training. Five (11%) were active in a network specifically for professional development. Eight trainers (17%) visited other training centres. Eleven trainers (24%) received mentoring, peer observation, or coaching training.

Recommendations to improve trainer capacity to train

The following recommendations, in order of frequency, were suggested by trainers:

Structural improvement:

• • Development of standards of training for trainers, including certification.

• • Greater formal recognition of training programmes.

• • Engagement with local or national training authorities/bodies, e.g. SAC in the United Kingdom, to improve trainer education and life-long learning.

Didactic improvement:

• • Formal in-person training courses for trainers.

• • Education on training assessment instruments, such as workplace assessments, objective structured clinical examination, and entrustable professional activities.

• • Webinars and online seminars on training.

Structured teaching for trainers and specific requirements

Although universities increasingly provide excellent degrees and courses in medical professional education (to certificate, Masters and PhD level), it is uncertain whether this is the best way to train trainers. Perhaps more targeted courses specifically focusing on what skills are required as a trainer are what is required. This was supported by 68% of the European trainers in this study recognising the need to further enrich their skills as a trainer. However, one-third did not recognise the requirement to develop any specific competence on the technical aspect of transferring knowledge, skills, and attitude to trainees. This group, which lacked the perception of the value of training trainers, was from a wide range of trainer experiences and from a wide range of programmes. An intervention for this group, on the value of educating trainers may have significant impact on the quality of their training and hence the quality of care provided by graduates to patients with CHD. Despite these sobering results, the majority of trainers expressed a need for formal “training the trainers” courses and development of standards in training. An interprofessional aspect to train the trainers workshop has been reported as very positive by other authors. ^{Reference Koffel and Reidt30}

Didactic content for training the trainers

The topic of training the trainers has been addressed by several recent papers.Reference Mustafa, Omar and Alnair ³¹ One study evaluated the best strategy to disseminate expertise top/down from a European or North American expert/trainer to an African trainer who then can disseminate the knowledge to other local doctors. This refers to the expertise itself and also to the instructional techniques used in training. Experience gained in the field and using measurable feedback methods has proven that teaching a medical discipline is more than just transferring knowledge and practical skills. The trainer must also be taught in teaching and facilitation techniques. Experience carried out in Sudan confirmed that delivering learning and teaching courses to teaching staff has positive effects on the trainers’ ability to have clear and well-stated learning objectives.Reference Mustafa, Omar and Alnair ³¹ Trainers improved their presentation skills and their use of different teaching methods, which further highlighted the stated learning outcomes and curricula design. By using a wider range of teaching and assessment methods, the students benefited, and their satisfaction was increased.Reference Olayo, Kirigia and Oliwa ^{32 –} Reference Corbett, Mathenge, Zondervan and Astbury ³³

There is an even distribution of trainers who have or have not attended educational courses across all parts of Europe, without any difference between Northern, Central, and Mediterranean countries. This reflects a lack of specific requirements to become an educator in paediatric and congenital cardiology all over Europe. This is highly relevant when one takes into account a survey of German trainees in which the majority of trainees themselves agreed on a promising career perspective, but many complained their training was lacking structure (47%) and lacking transparency (37%). ^{Reference Horst, Michel, Kubicki, Lang, Zschirnt and Moosmann34} Nevertheless, the opinion that training a discipline is different from practising a discipline is not shared by all trainers. Seventy per cent of the responders agreed or strongly agreed with the statement that they feel well qualified to provide training to the trainees.

Critical roles of the trainer

Successful training of trainers and trainees requires a systematic approach, structured curriculum, and protected time. Trainers in paediatric congenital cardiology are often facing multiple tasks beyond training. They serve as a doctor for the sick child, take responsibility as a training director or teacher, undertake research to advance the speciality, and are advocates for the subspeciality. Time constraints in providing training were reported by > 50% of trainers as the greatest challenge in providing training. Given the limited amount of time, the definition of goals for educating the specialist is essential. Therefore, the most important tasks of a good trainer are the implementation of innovations, the assumption of responsibility and the setting of an exemplary attitude. A successful trainer may take the task to transmit a broader vision and goals of the subspeciality rather than assigning the trainees tasks and work.

Trainers should also be aware of themselves as role models for trainees. Jochemsen-van der Leeuw et.al. categorised the roles of medical teachers in patient care qualities, teaching qualities, and personal qualities. ^{Reference Jochemsen-van der Leeuw, Wieringa-de Waard and van Dijk35} Excellent clinicians who were investing in the doctor-patient relationship were identified as positive role models. They inspired and taught trainees while carrying out other tasks, were patient, and had integrity. These identified attributes may help trainers to recognise which aspects of their clinical professional behaviour might be important for trainees in the process of learning professional competencies through observation. Attributes associated with trainers have been summarised for surgical trainers: “character” (approachability, patience, enthusiasm, encouraging/supportiveness), “procedural” (willingness to let trainee operate, balance between supervision and independence), “teamwork and communication” (sets educational aims and objectives, ability to use appropriate feedback, communication skills, and time availability to train) and “clinical” (capable, good relationships with patients, and the health care team). If these key attributes are valuable and have a positive effect on the training of trainees, they would need effective further evaluation before including these topics in teaching courses for trainers.Reference Jochemsen-van der Leeuw, Wieringa-de Waard and van Dijk ³⁵

Assessment of trainees

The prior long-standing teaching method of “See one, do one, teach one” is not adequate anymore from the didactic point of view. The trainer is expected to give teaching, followed by assessment and feedback. An important point raised by the survey is the disparity of the assessment techniques adopted throughout Europe. In all centres, trainees are assessed during their training while the instruments employed vary widely (Figure 5). Workplace assessments have been identified as mostly used (> 90% trainers) with a mix of summative and formative feedback as the most common type of assessment. The timing of the assessment varies from daily to monthly to biannually and annually. Although entrustable professional activities have been proven to be an effective way to evaluate trainees and foster responsibility according to their level of autonomy, knowledge of entrustable professional activities is limited amongst trainers. Furthermore, they are seldom adopted as they are perceived to be time-consuming and not really of value. The Association for European Paediatric and Congenital Cardiology Educational Committee is confident that entrustable professional activities will become a more widely adopted method of evaluation of trainees in the near future. Changing the training paradigm from a time-based to competency-based is an important step forward towards improving the standard of training across European countries.

Feedback to trainees

Feedback is provided by the majority of trainers, most commonly in verbal form. Considering that assessment is a fundamental component of education and an important driver of learning, a formal and possibly written feedback by the mentor evokes an emotional response by the trainee, which goes well beyond the assessment itself, being a powerful contribution to the process of the professional growth of the trainee. On the other hand, assessment and feedback require motivated and skilled assessors and represent a further workload.

Vision on the role of trainers

The relationship of trainers with their trainees is to transmit knowledge and experience while leaving space for innovation. The trainer–trainee relationship should allow trust and respect from both sides. The trainer should be a mentor, not a judge. This core vision of being a trainer is essential to removing obstacles to success. As a mentor, the trainer should allow dedicated time for transmitting professional knowledge, soft skills and supporting the personal development of the trainee. Stimulating career development as well as facilitating the growth of the person are important goals during the training of fellows.

Most importantly, training brings mutual benefits to the trainer and trainee. The trainer also evolves during the trainer process, becoming more self-reflective and more aware of his/her practice. There are two models as a trainer: first as a role model for being a good physician (a caring physician aiming to deliver patient-centred care, a caring colleague and team member, and a good leader) and second as a teacher for clinical discipline-specific skills. The first one is more complex and more difficult to achieve, and is heavily embedded in the culture of the person, institution, and system; the second one requires education and a more structured approach.

To succeed in both approaches requires strongly motivated trainers, given that many of them also have a significant clinical workload. The 3C model is an effective model for trainers to follow. ^{Reference Kehr36} For explicit motives (the head), clearly set goals should be set for trainers, incentives and recognition, and education on the importance of training. For implicit motives (the heart), a positive culture should be adopted in the department/institution, sharing of experiences among trainers, and a way to recognise the effects your training gave. Didactic tools, such as structured training programmes, and teaching to provide feedback are important components of such a model.

It is not only the trainees who ideally should be exposed to different trainers, but also the trainers who should exchange their experiences with each other, to develop in a natural setting, find new motivators and create a culture. It is important to recognise that there is no “gold standard” for a good physician as such. Specific competencies (skills) matter a lot, but typically, there is a balance between different qualities (personal, clinical, etc.). Thus, it is important to be dynamic and self-reflective, always evolving towards becoming a better physician, which also requires different types of interactions, trainer-trainee, trainee-trainer, trainer-trainer, if we look beyond interactions with patients.

Recognising the role of the trainer as one of the essentials for a well-functioning, high-quality healthcare system (i.e. systematic programmes within medical schools to prepare trainers, dedicating protecting time, incentivization, formal and public recognition) is essential to change the paradigm.

Keeping in mind that an important part of the medical profession can be compared with mastering an art, the support of individual talents of trainees and teaching them to master the details of the profession remains extremely important. Despite all structured training and assessment goals, individual human qualities important for interaction with patients and families could be learned from being trained by different individual trainers.

Role of associations and authorities

In the absence of National and European legal requirements to become a trainer in health sciences, the role of Scientific Associations can be very important and should be proactive. The documented interest of Association for European Paediatric and Congenital Cardiology trainers in this topic by replying to the questionnaire reinforces the Association for European Paediatric and Congenital Cardiology Educational Committee and Council’s decision to continue the endeavour of creating a culture of training the trainers at all levels in Europe.

The Association for European Paediatric and Congenital Cardiology could work together with the Union of Medical Specialists and the Council for Specialist European Medical assessment, the oldest and most representative organisations dealing with the standardisation of training in medical specialities, to create guidelines for the education of medical trainers. Minimum requirements to be certified as a competent and updated trainer in Paediatric and Congenital Cardiology could be harmonised at a supra-national level and proposed to the European and National authorities as a standard of education for trainers in medical specialties.

At a basic level, the Association for European Paediatric and Congenital Cardiology is actually creating awareness that training the trainers is an important strategy to deliver a training programme able to prepare excellent specialists who will deliver the best possible care to paediatric and CHD patients. Furthermore, the Association for European Paediatric and Congenital Cardiology can facilitate the education of trainers providing courses, webinars, and in-person meetings. These should focus on theoretical, technical, and practical aspects of the “art” of teaching a medical discipline, stay current on changing requirements and regulations, and allow professional development and networking opportunities.