With the publication of the 2015 version of the Training Guidelines for Pediatric Cardiology Fellowship Programs,¹ the field is entering a new way of thinking about training and evaluating fellows. The major change from the original 2005 guidelines² is the shift away from a requirement for performing a fixed number of procedures in a subspecialty, to requiring performance of a minimal number to allow the faculty to adequately evaluate the level of competence for each year of training.

Several events that have occurred over the last decade necessitate this philosophical change in the way programs evaluate and provide feedback to pediatric cardiology trainees. Duty hour regulations have limited the number of hours a day and days a week that trainees can be in the hospital. At the same time, the curriculum has expanded markedly as technology, knowledge, and subspecialization has grown. Therefore, programs have to find ways to ensure that graduates have acquired the knowledge and skills required to move successfully into further subspecialty training or into a faculty position.

The 2015 guidelines utilize entrustable professional activities (EPAs) to describe broad areas within a specialty that must be mastered in order to graduate. For pediatrics, there are seven EPAs that apply to all subspecialties and an additional six that are specific to pediatric cardiology. The levels of competence for each are defined on a five-point scale with the goal of achieving at least a level 4 by graduation. Level 4 confirms that "the fellow may act independently upon graduation" to perform each EPA, such as to "diagnose and manage congenital or acquired cardiac problems." The specific curriculum and the evaluation tools for each milestone and how they relate to the six core competencies are delineated in each Task Force chapter. Achieving level 5, at which point "the graduate may act as a supervisor and instructor," should be a goal over time for the board-certified cardiologist, particularly in one's chosen areas of interest.

Training program directors and faculty will be required to intensify their direct observation of fellows in all aspects of performance and to give feedback in the form of achieved milestones for each task. Those fellows who meet or exceed the competence of their peers will be encouraged to strive for the next level of milestone achievement, while those not meeting the desired level of competence will need specific instructions on how to improve to meet and then exceed these milestones. This may include doing a greater number of procedures under supervision and/or spending more time in that particular area.

Halfway through their core fellowship, many often find an area they want to concentrate on after graduation, a gradual training process with variable timing. Fellows who have successfully reached the milestones in all areas of pediatric cardiology may be able to concentrate a portion of the remaining time to an area of interest. This is particularly true for those who have been successful or are making great strides towards completing their research requirements early on.

It has been found that assigning the senior fellows to complete a month as "acting attendings" toward the end of training is a great way to give them the experience of leading a cardiology team in the care of hospitalized patients, seeing consultations, and teaching residents and medical students. This is done under the supervision of the actual attending, who is available on demand and meets frequently with the fellow to mentor this experience. This can build confidence as final preparations for the next career stage is made.

The decision as to what to do after fellowship can be daunting. Some fellows feel a strong calling early on for a particular subspecialty and begin the application process for advanced training in their second year. However, the job market fluctuates and openings in this subspecialty may not be available at that particular moment in time. Likewise, those seeking a job in general cardiology or noninvasive imaging without a fourth year of training may face the challenge of locating the "right" position that fits their desired job descriptions and the needs of spouses or significant others' careers in appropriate geographical areas. Leaders in the field have started a project to assess the current perceived cardiology job market and plan to repeat this survey every two years so that fellows and residents interested in pediatric cardiology have data on which to base their decisions. It is generally true that hard-working, successful fellows who demonstrate excellent patient care, love to teach, and advance the field with novel research will be sought after completion of training. These individuals will be called upon to grow into future leadership roles in the field.

References

1. Ross RD, Brook M, Feinstein JA, et al. SPCTPD/ACC/AAP/AHA 2015 training guidelines for pediatric cardiology fellowship programs (revision of the 2005 training guidelines for pediatric cardiology fellowship programs). J Am Coll Cardiol 2015 Mar 13. [Epub ahead of print]
2. Graham TP, Beekman RH. Training guidelines for pediatric cardiology fellowship programs. J Am Coll Cardiol 2005;46:1380-403.

Keywords: Cardiology, Child, Curriculum, Data Collection, Faculty, Fellowships and Scholarships, Leadership, Mentors, Patient Care, Pediatrics, Referral and Consultation, Research, Students, Medical

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