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Congenital Heart Surgeons Society Summer Retreat, August, 2005
Topic
Congenital Heart Surgery Training in the United States
The purpose of the CHSS Summer Retreat at the Chicago Hilton on August 26th
and 27th, 2005 was to address the important issue of resident/fellow education in the
context of the initiatives leading to an organized ACGME approved congenital heart
surgery fellowship supported by the Residency Review Committee and the American
Board of Thoracic Surgery.
The CHSS was the logical organization to deal with the various issues that will
arise as this program takes shape through the vetting process led by the American Board
of Thoracic Surgery. To this end, the retreat centered on: the just completed congenital
heart surgery manpower study, the historical aspects of congenital heart surgery training
in America, a review of some selected training programs in the United States and Canada,
the future of foreign training programs, the future of adult congenital heart surgery, and
the idea of instituting a subspecialty Board of Congenital Heart Surgery. Other significant
issues were addressed such as curriculum development, program criteria, length of
fellowships, and the like.
United States and Canadian Congenital Heart Surgery Manpower Study
Marshall Jacobs presented the “work-in-process” results of the congenital heart
surgery manpower study that was performed in association with the STS. This study was
submitted for presentation to the Society of Thoracic Surgeons for the January 2006
scientific meeting. There were some very interesting findings that were noted and
discussed at the meeting. Of note, the study identified and sent out questionnaires to 263
“congenital heart surgeons” in the United States and Canada and received 233 for a
response rate of 89%. Several of these 233 were retired, fellows, or no longer performing
congenital heart surgery and were therefore eliminated leaving 215 congenital heart
surgeons as the study group. Of these 25 surgeons listed themselves as performing less
than 25 congenital cases per year. That left a core group of 190 congenital heart surgeons
who performed more than 25 cases per year. The demographic statistics that were
catalogued on these respondents centered on previous training experiences, time in
service, research activities, career satisfaction, and time until retirement, among others.
Also included in the analysis was the number of fellows that are being trained in the
United States and Canada compared to the anticipated rate of retirements. In particular,
25 respondents stated that they will retire from practice within the next five years, i.e. 5
retirements per year over the next 5 years. This compares with 39 fellows per year that
are now being trained in the United States and Canada per year, 19 of which are expected
to enter into the American job market. In other words on the average, 5 established
congenital heart surgeons are retiring per year and are being replaced by 19 trainees
expecting to find positions in the United States and Canada. These data do not take into
consideration attrition due to sickness, accidents, early retirement, or the possibility of
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increased case load due to the enlarging population of adults with unresolved congenital
heart disease. Marshall Jacobs stressed that these data represent a “snap-shot” of the
existing job market conditions and may not be exactly predictive of what will occur in the
future. A copy of his slides is not included in this synopsis because the work is expected
to be presented to the STS meeting in January, 2006. He wanted to avoid duplicate
presentations.
Introduction and Historical Aspects of Congenital Heart Surgery Training in the USA and
Overview of the Summer Retreat
Constantine Mavroudis presented a review of the various congenital heart surgery
training methods in the United States over the last 50 years (Appendix A). The “home
grown model” involves residents being identified in the training process and take
advantage of a career training position within their own or other institution resulting in
staged development of their career pathway. The foreign grown model has two
components. The first involves American residents traveling abroad for training and
return to seek faculty appointments based on their training experience. The second
component involves foreign nationals applying for positions in the United States based on
the existing local needs and the established talents of the surgeon. This option usually
requires some political intervention as some governmental level. The third model is the
“one year fellowship” model which involves a resident to enter into a one year position
after completion of an ACGME training program in Thoracic Surgery. The program
requires the fellow to gain the necessary skills to perform congenital heart surgery and
secure a position after the fellowship, all within one year.
Constantine continued his presentation with an analysis of the European
manpower study and how it compares to the United States (EJCTS 2003; 24:343-351).
He then reviewed what has been achieved already by the RRC, the ABTS, and the
process by which the new system will be vetted.
The discussion points included a review of the extant USA training system, a
discussion of the impact and future status of the foreign training programs, i.e. GOS,
Toronto Sick Kids, a review of adult congenital heart surgery, a discussion of case mix
requirements, and collaboration between the CHSS and the ABTS.
The goals of the retreat (Appendix B) were to: (1) affirm the directions of the
RRC and the ABTS, (2) develop criteria for training program certification, (3) develop
curriculum guidelines for trainees, (4) resolve foreign program certification issues, (5)
institute an informal career development pathway for most trainees, and (6) formulate an
overall consensus for congenital heart surgery training in the United States.
View from the American Board of Thoracic Surgery
Irv Kron developed his slide presentation (appendix C) but because of important
personal commitments, could not deliver his presentation. Ed Bove delivered his talk in
his absence. The salient points of Irv’s message were: (1) there was a lack of uniformity
in congenital heart surgery training, (2) that the technical complexity of congenital heart
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surgery is increasing, and (3) that is about time that congenital heart surgery be
recognized as a separate specialty requiring extra training. He opined that the CHSS will
have a major role in assisting the ABTS in the examination process and curriculum
development. He also noted that the ABTS has appointed a committee led by Ed Bove to
develop the Board Certification process. He also raised the idea of career development
positions and opportunities which will allow the certified diplomate to develop and
progress during the remainder of his/her professional career. He suggested that the CHSS
will have a major role to play involving this issue. He summarized: that ACGME
residencies in congenital heart surgery will be approved, that a ABTS certificate will
likely occur, that apprenticeships should transform at least partially into curriculum based
education, and that we should monitor our graduates as they move into career
development positions.
The Boston Experience
John Mayer, Jr outlined some fundamental principles that should be considered as
we move forward with the congenital heart surgery training certification process
(Appendix D). These principles include the following:
•
•
•
•
•
An important role for professions is to expand a body of knowledge and to convey
that knowledge to the current and future members of the profession
The right to self-regulate is fundamental characteristic of a profession
A society grants privileges and prerogatives to a profession only as long as it
believes that the profession is acting in that society’s interest
Professional growth and education does not end with the conclusion of formal
training in a specialty
In an atmosphere of increased public, regulatory, and payor focus on outcomes,
“learning curves” are poorly tolerated
John outlined the training system at Boston Children’s Hospital over the years and
stressed the importance of the career development model where a junior faculty member
of the department attains increasing levels of responsibility and competence with time in
service. He presented data to support this type of training and are included in Appendix
D.
The Stanford/UCSF Experience
Frank Hanley presented his experience with training models that he developed in
concert with a multiple site congenital heart surgery program (Appendix E). He
summarized the increasing number of cases that have been associated with such a
program and the tenets that have led to competent congenital heart surgery graduates of
the program. In his own words,
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“The issue:
It is acknowledged that the certification process will represent a milestone indicating a
reasonable level of competence in the trainee, but that it does not signal full maturation of
the individual as a congenital heart surgeon. (What defines “reasonable level of
competence” is a separate discussion.) It is probably fair to say that the ideal training
period required to meet this criterion will vary depending on the individual trainee and
program; however, for practical reasons it will be necessary to standardize duration of
training that in balance assures the desired level of competence in the great majority of
trainees. It is generally accepted that less than one year is inadequate, even in programs
that provide ideal resources to the trainee. It is also accepted that a period longer than two
years is unrealistic considering the prior training that is required in general and
cardiothoracic surgery.
My perspective:
Based on my experience as a program director, having trained twenty four fellows over
the past twelve years, I believe that the duration of the fellowship should be viewed as a
period in which the trainee is immersed in the world of congenital heart disease, and not
just as a practical vehicle for acquiring a certain number of cases as operative surgeon.
Too much focus on the case volume can create the most dangerous of all situations, i.e.
the individual with good technical skills, and the narrow confidence that goes with it,
who has poor insight and judgment. Although the number of cases that the trainee
performs as operating surgeon, and the technical expertise that this number represents, is
one important measure of adequate training, it is not the only one. This is particularly
true in congenital heart disease in which there is such great variability in age, lesions, and
treatment options for specific lesions. As important are gaining experience in
preoperative evaluation, judgment regarding timing of intervention, intraoperative
decision making, and appreciation of alternative management options, to name just a few.
It is my belief that the period of immersion that is required before a trainee has developed
all of these skills to the degree necessary to reasonably insure success as an independent
surgeon, is most often two years, rather than one.
The environment and resources of the training program are important factors as well. If,
for example, a program has a total volume is 125 cases per year, it is my belief that it will
be difficult to adequately train a fellow, even if the faculty demonstrates the extraordinary
dedication of giving the trainee 100, or more, of these cases. Much of the experience
gained by the trainee comes from acute observation of clinical material for which he/she
did not act as operating surgeon. Here is one example of what I mean. Initially, the
learning curve for a trainee will be steep, and very worthwhile, if the trainee acts only as
first assistant helping an experienced faculty member repeatedly with repair of a certain
lesion, let us say primary repair of infant tetralogy of Fallot. After a certain number of
cases as first assistant and observer, however, the learning curve will plateau. The trainee
will have absorbed most of what he is capable of absorbing at that point . If the faculty
member then takes the trainee through an infant TOF repair, a new learning curve will be
initiated. After a number of cases as primary surgeon (the exact number will vary) the
trainee’s new learning curve will again begin to plateau. This is not the end of the
process, however. If then the trainee again assists the faculty member with an infant TOF
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repair, becoming the observer again after having performed a few himself, he will enter a
new learning curve as observer which he was not intellectually capable of before. He will
now be focusing on 10 or 20 little maneuvers during the course of the operation that,
prior to doing a few himself, he did not even realize were important. This kind of give
and take can be extended beyond this concrete example to all of the skills, knowledge,
and judgments that we must develop and transfer to the trainee. I do not think it can be
done well, in the majority of instances, in less than two years or in programs that must
force the numbers so that the trainee meets criteria for case volume.
Another point. Given the initial orientation and break-in period that is always necessary
in the first few months of fellowship, and the level of case complexity that exists today, it
also seems unrealistic, and even irresponsible, to expect that a fellow will perform more
than half of the cases in a full service program. And, of course, if it is not a full service
program, there should not be a fellowship there. So, I believe program case volume needs
to be considered as an important factor. I am a little hesitant to throw out specific
numbers, but as an initial estimate I think a fellow should perform one hundred cases per
year as surgeon (that is two per week), and the program should have a minimal case
volume of 250 per year. It seems that anything less than this will not provide the
opportunity for the trainee to mature to the level desired over a two year period.
I believe this 2 year fellowship should mark the end of formal training. We should
however provide other recommendations or guidelines:
1) Institutions starting up a new program should not consider recruiting individuals
right out of training for the position of surgical program director.
2) Institutions with an existing program and a senior surgeon who himself does not
perform the entire spectrum of cardiac surgical procedures, should not recruit
individuals right out of training with the expectation that the new recruit will
extend the spectrum of cases.
Institutions with full service programs that recruit individuals right out of training should
do so with the expectation that further mentoring from senior colleagues will be needed
for a period that ranges from one to several years.”
The Ann Arbor Experience
Ed Bove presented the Ann Arbor experience with congenital heart surgery
training (Appendix F). His talk centered on the following factors that influence a
fellowship program which include:
 Center volume
 Case mix, severity
 Surgeon volume
 Support services
 Cardiology, anesthesia, ICU, hospital environment
 Service/manpower needs
 Education
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He continued his discussion noting the difficulties of training in today’s environment
which include:
 Shift to early surgery
 Neonatal repairs
 Impact of interventional procedures
 Work hour restrictions
 Limited job opportunities
 Consumer, payor, hospital demands
 “Microscope” environment
He noted that the training period is quite long in the United States and offered some
important reasons to change:
 Interest among potential trainees declining:
 Long hours, grueling residency
 Poor job market
 Loss of traditional stature in society
 Competition from interventional cardiology
 Declining reimbursement
 Inability to control life-style
 Particularly unattractive to women
He opined that 12 months of continuous training would suffice if the program were
structured favorably. Alternatively, he noted that a 24 month program would be the
maximum. Other important requirements are noted:
 12 months continuous training
 24 months maximum*
 Academic medical center*
 Program minimal volume of 300 cases/yr*
 Dedicated pediatric heart service
 Dedicated congenital heart surgeons (>2)
 Single program director
 Defined curriculum to include:
 Didactic lecture series, D&C, journal club, teaching rounds
 Academic project (clinical, basic science)
 Dedicated rotations* in:
 Catheterization lab
 Echo lab,? other imaging (e.g., MRI)
 ICU, outpatient clinic
 Minimal operative case exposure
 Surgeon: 75 cases (VSD 5, AVSD 4, switch 4, CoA 4, tetralogy 4, CPA 5)
 1st assistant: 100 cases*
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 Duty Hours
 80 hour work-week regulations apply
 Board Certification
 Written and oral exam
Because of the total length of the overall program he suggested that a newly
engineered program might include:
 Years 1-3
 Basic general surgery, critical care
 Year 4: “Swing Year”
 General and thoracic surgery
 Some adult cardiac surgery
 Year 5:
 Adult cardiac surgery
 Years 6 & 7:
 Congenital heart surgery
Adult Congenital Heart Surgery
Joseph Dearani presented the Mayo Clinic experience of postgraduate training in
congenital heart surgery (Appendix G). His charge was to review the growing population
of adults with congenital heart disease who for some reason or another will require
primary or secondary operations for late diagnosis, residual defects, or mandatory
reoperations due to conduit replacements and the like.
While the prognosis is for an increasing case load in the future for the congenital
heart surgeon, no one really knows what the impact will be. He stressed that these
operations must be performed by congenital heart surgeons in adult hospitals or pediatric
hospitals that have addressed the special needs of the adult patient. His summary of
congenital heart surgery training is the following:
•
•
•
Fellowship should be primarily in a high volume children’s hospital
+ additional time with ACHD depending on practice opportunity
Challenges: multiple reoperations, valves, arrhythmias, coronary disease
Congenital Heart Surgery Training in Canada
William Williams presented the Toronto experience with congenital heart surgery
training and the perquisite requirements for admission into such a residency (Appendix
H). He reviewed the substantial commitment and contribution that the Toronto training
program has had in filling faculty positions in Canada and in countries around the world,
including the United States. He stressed the importance of clinical experience in adult
congenital heart surgery and the necessity of a high volume unit to achieve the necessary
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environment for congenital heart surgery training. He concluded that the training program
should be for an uninterrupted period of two years.
Congenital Heart Surgery Training in The United Kingdom (Great Ormond Street)
Jeffrey Jacobs presented the congenital heart surgery training experience at Great
Ormond Street (GOS) with the collaboration of Martin Elliott (Appendix I). Jeff
reviewed the contribution that the GOS training program has had in the United States and
offered that when Jarda Stark retired a few years ago, 50% of the practicing US
congenital heart surgeons then practicing had worked with him. He also chronicled the
effect that decreased duty hours have had on the overall administration of the program.
Nevertheless, the GOS experience continues to provide an excellent training opportunity.
To emphasize his point as to the importance of the GOS training program, he noted by
name the past trainees who are now or have been in the past practicing congenital heart
surgery in the United States or elsewhere.
Jaroslav Stark, MD
Eliot R. Rosenkranz, MD
Douglas M. Behrendt, MD
Gary Lofland, MD
David Robinson Clarke, MD Leslie Hamilton, MD
Willem Daenen, MD
Mike Dewar, MD
Marc R. de Leval, MD, FRCS Charles Huddleston, MD
Frank Midgley, MD
J. William Gaynor, MD
A J Furst, MD
Edward L. Bove, MD
Jim Sink, MD
M. Haw, MD
John Mark Morales, MD
H. Jalali, MD
Walter Merrill, MD
Tom Roland Karl, MS, MD
Davis Drinkwater, MD
Ralph E. Delius, MD
Nihal A Weerasena, MD
Jeffrey Phillip Jacobs, MD
Martin J. Elliott, MD, FRCS Khanh H. Nguyen, MD
Richard Hopkins, MD
John Stevens, MD
Kim Duncan, MD
Victor O. Morell, MD
Steven Gundry, MD
Vaughn Starnes, MD
Christian Pizarro, MD
Gordon Cohen, MD, PhD
C. van Doorn, MD
Ali Dodge-Khatami, MD
Marco Ricci, MD
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To emphasize the overall importance of the GOS training program to the United States,
he also noted the names of those who have trained at the GOS program and are now
practicing congenital heart surgery in the United States.
Edward L. Bove, MD
David Robinson Clarke, MD
Tom Roland Karl, MS, MD
Richard Hopkins, MD
Jeffrey Jacobs, MD
Gary Lofland, MD
Vaughn Starnes, MD
Eliot R. Rosenkranz, MD
John Mark Morales, MD
Victor O. Morell, MD
Gordon Cohen, MD, PhD
Christian Pizarro, MD
Jeff recommended that any congenital heart surgery residency credentialing scenario
must include opportunity to train overseas at programs such as GOS and still become
certified.
Afternoon Discussion Session
As the discussion matured, it became evident that some ongoing congenital heart
surgery organization would be necessary to review the training process over time, to
liaison with the ABTS and RRC concerning training issues, and to establish a forum that
would allow congenital heart surgeons to have input into the training of congenital heart
surgery fellows and thoracic surgery residents who rotate through the congenital heart
surgery service. While this informal organizational structure had its birth at the 2005
CHSS Summer Retreat, it became obvious that some other structure would be necessary
to define the goals and establish the guidelines under which congenital heart surgery
training programs would perform the task of training congenital heart surgeons and
providing a meaningful experience in congenital heart surgery for thoracic surgery
residents.
The committee structure that emerged from the 2005 CHSS Retreat took into
consideration three important elements of training.
(1)
The first committee is a liaison committee that would serve as a
consultative body to the ABTS to support question writing functions
applicable to the congenital heart surgery fellowship and to the thoracic
surgery residency. This committee would also note the results of the
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(2)
(3)
examination and monitor the educational strengths and weaknesses of the
collective training experience of fellows and residents based on the results
of the examinations and the specific structure of the training programs.
The idea is to provide feedback to the training programs on how the
residents and fellows have performed, which would result in improved
education and training.
The second committee was charged in an advisory role: (a) to help
develop the curriculum of the new congenital heart surgery training
program, (b) to help create criteria for program development including
length of fellowship, case mix criteria, adult congenital and (c) maternity
leave issues.
The third committee was created to address the future status of foreign
training programs that have been responsible over the years for so many
congenital heart surgery practitioners in America. Specifically, the
programs at Great Ormand Street (United Kingdom) and Toronto Sick
Kids (Canada) were discussed owing to the fact that so many congenital
heart surgeons in America had their training at one of these two
institutions. This committee will be charged to review and clarify these
relationships as they relate to the RRC and the ABTS, which are American
(United States) reviewing bodies that do not certify foreign programs per
se.
The organizational structure and committee assignments are meant to be advisory bodies
to the ABTS as this process moves forward. The CHSS members feel that their thoughts
should be noted and heard as a committee of the whole. The committee assignments are
as follows:
A. ABTS Board Examination Liaison Committee
1) Question Bank for Thoracic Residency and Congenital Fellowship
2) Question Assessment and Feedback to CHSS
1) Leads to improved Resident/Fellow Education
3) Committee Members
1) Carl Backer, Chairman
2) Marshall Jacobs
3) Peter Manning
4) Charles Huddleston
5) James Jaggers
6) William Gaynor
7) Scott Bradley
B. Build the Curriculum
1) Help to Create the Educational Structure based on ABTS/RRC
requirements
2) Help to Create Criteria for Program Development
1) Length of Fellowship
2) Case Mix Requirement including Adult Congenital
3) Maternity Leave
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3) Continuous Review and Reassessment
4) Committee Members
1) Frank Hanley, Chairman
2) Ed Bove
3) John Mayer
4) Thomas Spray
5) Hal Walters
6) Erle Austin
7) Irving Shen
8) Kirk Kanter
9) Karla Christian
C. Foreign Programs
1) GOS; Toronto
2) Establish Criteria
3) Clarify the Relationships
4) Committee Members
1) Marshall Jacobs, Richard Jonas, and William Williams, CoChairmen
2) Jeffery Jacobs
3) David Clarke
4) Christo Tchervenkov
5) Charles Fraser
6) Christian Pizzaro
So, what would be the other structure that could take on these functions and
responsibilities moving forward? Obviously these functions would require yearly or
biyearly meetings to assess the progress of the new congenital heart surgery programs
and to assess how the rotating residents in thoracic surgery are being educated.
Refinements in curriculum, institution of e-learning modules, and other educational tools
need to be evaluated.
After the summer retreat several telephone conversations resulted in a proposition
that would answer these questions and establish a bone fide organizational structure that
would have liaison capabilities with the American Board of Thoracic Surgery, the Joint
Council for Thoracic Surgical Education, and others. This new organizational structure
would become a Council of the extant Thoracic Surgery Directors Association. All of the
aforementioned committees that were developed by this CHSS Summer Retreat would be
folded into this new organization. This idea was suggested by Jeff Gold, the present
President of the TSDA. He reasoned that the TSDA has the entire established
infrastructure to deal with the various proposed functions that the Congenital Heart
Surgery Council will need such as: new educational initiatives, curriculum oversight,
post-fellowship clinical tracking of diplomates, resident match procedures, and the like.
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What are the next steps?
The CHSS Summer Retreat established the committees that could serve as an
advisory body to the ABTS as the congenital heart surgery training process moves
forward. These committees were formed in order to consider all the issues that were
opined at the Retreat. The members of the CHSS viewed this function as their collective
duty. To this end, the committees will study their charge and form recommendations to
the ABTS relating to their charge. The committees are broadly represented and the
process should yield a consensus as we move forward with this important initiative.
It appeared to many that the initial expectation was that the CHSS would be the
logical organization to carry out the necessary advisory functions to the ABTS. However,
the creation of a new organization based only on the virtues of resident/fellow education
would carry with it the structured, relevant, and focused activities that would give the
congenital heart surgery community an important voice in the administration of what we
do, namely perform congenital heart surgery and prepare the next generation of
congenital heart surgeons for the task. An organization devoted to this endeavor would
necessarily be an important force that would immediately have the ear of the ABTS and
the RRC through the parent organization, the TSDA.
The structure of the congenital heart surgery council would be slightly different
than the TSDA. Just for starters, the number of members would reflect the small number
of training programs that are necessary. This number might be 10-12 programs, which
would include 10-12 program directors. In addition to these 12 congenital heart surgery
program directors, an additional 12 members would populate the Council from other
thoracic surgery programs with active congenital heart surgery programs which do not
have an approved congenital heart surgery fellowship program. The reason for this
representation is to allow those programs to have input into the training process for a
number of reasons. First of all, these programs will be hiring the trainees that will
graduate from these programs and populate the positions that will be made available by
retirement. These programs should have some representation into the process that will
train the new generation of congenital heart surgeons. Furthermore, the programs without
fellowships will be training the rotating residents from their own thoracic training
program. Their influence in this Council will help to form curricula for both the
congenital heart surgery fellow and the rotating thoracic surgery resident. These 10-12
members will be appointed by some organized process yet to be determined. Ideally
therefore, the congenital heart surgery Council will have 24 members that will establish
the organizational structure overseeing the curricula and associated functions of
congenital heart surgery training.
The initial population of the new Council will obviously be determined by those
members who have successfully completed the certification process leading to an
established ACGME congenital heart surgery training program. The other members as
noted above will be appointed by a different process.
Conclusion
The meeting ended with a directive by the overwhelming majority of the CHSS
members present that the ABTS process to establish a specialty board with all the
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requirements thereto pertaining be postponed in order for our committees to consider
their charges and offer considered opinions and recommendations as to the structure,
requirements, and particulars under which such a specialty board will function. The three
committees will be contacted. Their work should progress immediately and have
considered recommendations which will be communicated to the ABTS from the CHSS.
The rest is up to the ABTS.