CVD Fellowship Training in Cardio-Obstetrics: Key Points

Davis MB, Bello NA, Berlacher K, et al.
Cardiovascular Fellowship Training in Cardio-Obstetrics: JACC Review Topic of the Week. J Am Coll Cardiol 2023;82:1792-1803.

The following are key points to remember from a review on cardiovascular disease (CVD) fellowship training in cardio-obstetrics:

  1. The Accreditation Council for Graduate Medical Education Common Program Requirements for CVD fellowship training includes competency in heart disease in pregnancy; however, beyond this there are no recommendations of how this competency can or should be achieved within fellowship programs. The American Board of Internal Medicine does not include cardio-obstetrics as a part of its certification requirements, and the Core Cardiology Training Statement, last revised in 2015, is vague regarding recommendations for care of the pregnant patient. Given that guidance on education in this field is currently lacking, there is a need for recommendations on standardized training and education for CVD fellowship programs.
  2. In this review topic of the week, Davis and colleagues lay down the need for the foundational elements of cardio-obstetric training. The authors focus on understanding of reproductive health, contraceptive considerations, pregnancy physiology and hemodynamics, and short- and long-term CV implications of pregnancy for a birthing patient and the developing fetus. They define the domains of competency in the field in four major criteria: clinical care, research, education, and advocacy.
  3. The proposed framework of training includes the traditional Levels I, II, and III, similar to other competencies in cardiology subspecialties. All cardiologists should understand the hemodynamic changes of pregnancy and the safety of CV medications during pregnancy and lactation, understand the contraceptive options, accurately assess levels of risk, and participate in patient care experiences within the standard inpatient or outpatient experience. This would classify as Level I training and competency. This is not sufficient for managing high-risk cardio-obstetric patients.
  4. Level II should include an additional 3-6 months of training in cardio-obstetrics. As a guideline, trainees who complete Level II cardio-obstetrics training will have completed ≥60 unique consultations on cardio-obstetrics patients in interdisciplinary clinics with exposure to experts from multidisciplinary teams such as maternal fetal medicine, family planning, and obstetrics anesthesiology. The writing group acknowledges the need for research and/or quality improvement projects.
  5. Level III training is intended for cardiologists who aspire to lead dedicated cardio-obstetrics programs and/or provide care for the highest risk patients in a multidisciplinary manner. Significant exposure to various types of patients with the highest level of complexity is needed to develop the skills for care of these patients. As a guideline, training should include active involvement with ≥120 unique cardio-obstetrics consultations. A scholarly project focused on cardio-obstetrics is considered essential for level III training. This training should include experiential training of ≥6 months at high-volume centers or ≥12 months of training within the scope of the traditional training CVD fellowship.
  6. The authors recognize a variety of formats may be utilized including case-based conferences, journal clubs, podcasts, webinars, and national or international meetings. Synchronous and asynchronous digital education can be an important method of education in training programs without faculty with expertise in cardio-obstetrics. All CVD fellowship program curriculum should include education on core cardio-obstetric medical knowledge topics.
  7. For those who are unable to attain Level II or III training at their institution, rotating at other high-volume centers in recommended. Online educational modules could also be utilized to supplement training when other opportunities are unavailable.
  8. The document also focuses on assessment of competency and the learning environments to include multidisciplinary team members, especially maternal fetal medicines. Assessment of the trainees’ readiness to practice independently in the field of cardio-obstetrics can be demonstrated by their ability to accurately counsel, diagnose, and manage patients, from preconception to postpartum.
  9. Assessment should include direct observation by faculty with expertise in cardio-obstetrics. Multisource evaluations, including from faculty in other specialties in which a trainee has relevant patient care experience, should be used to document achievement of competency in cardio-obstetrics. Case logs and record of participation in didactics should be kept, providing evidence of relevant experience.
  10. The CVD fellowship program director and the Clinical Competency Committee of the fellowship program should review all evaluation and performance information for a trainee, specifically focusing on the medical knowledge and patient care skills specific to cardio-obstetrics and in collaboration with faculty with expertise in cardio-obstetrics. This document standardizes the expectations in training cardiologists proficient in the management of pregnant and reproductive-age individuals with cardiac disease.

Clinical Topics: Prevention

Keywords: Fellows in Training, Obstetrics, Pregnancy

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