Author + information
- ∗Newark Beth Israel Medical Center and Children’s Hospital of New Jersey, Newark, New Jersey
- †Children’s Hospital of Pennsylvania/University of Pennsylvania, Philadelphia, Pennsylvania
- ↵∗Reprint requests and correspondence:
Dr. Pankaj Madan, Center for Adult Congenital Heart Disease, Newark Beth Israel Medical Center and Children’s Hospital of New Jersey, 201 Lyons Avenue, Newark, New Jersey 07112.
Surgical and medical advances over the past few decades have now enabled >90% of children born with congenital heart disease (CHD) to survive until adulthood. Current estimates indicate that there are now more adults with CHD than children, with approximately 1.3 million adults living in the United States alone. In response to an increasing population of affected adults, adult congenital heart disease (ACHD) as a specialty was recognized in 1990, and in 2001, the 32nd Bethesda Conference recommended that care be delivered to this complex patient population by ACHD specialists in dedicated ACHD centers (1). There are, however, inadequate numbers of such specialists, and we are currently faced with a dire workforce shortage to care for this growing population.
ACHD Training Pathway and Board Certification
In 2011, the American Board of Medical Specialties recognized ACHD as a separate subspecialty of cardiology and put forth guidelines toward ACHD subspecialty certification. The ACHD board certification is offered through the American Board of Internal Medicine and is available to those with a valid American Board of Internal Medicine certification in cardiovascular disease or certification from the American Board of Pediatrics in pediatric cardiology. To become certified in the subspecialty of ACHD, trainees must complete ACHD fellowship training and pass the board certification examination, which will be offered for the first time in 2015 and every other year thereafter.
Trainees may have a background in internal medicine, pediatrics, or combined residency training in internal medicine and pediatrics. After completion of adult or pediatric cardiology fellowship, ACHD fellowship training is a 24-month commitment, including 18 months of full-time clinical training and 6 months of elective clinical or research experience. Guidelines specify that during the 2-year training program, the trainee should spend 9 to 12 months on inpatient service and/or ACHD consultative service; 3 months in ACHD imaging, including echocardiography and cardiac magnetic resonance imaging; 2 months in cardiac catheterization of the ACHD patient; and 1 month in the intensive care unit caring for post-operative patients. Trainees with pediatric cardiology backgrounds should spend 2 months taking care of general adult cardiology inpatients, and those from an adult cardiology training background should spend 2 months caring for pediatric CHD patients or in adolescent medicine.
These guidelines also allow ACHD fellows to customize their training experience by providing a 6-month clinical or research elective. Depending upon the fellow’s interests, these electives may be an option to gain additional expertise in advanced echocardiography, cardiac magnetic resonance imaging, pulmonary hypertension, or heart failure/transplantation. Alternately, this time period can be used to focus on a dedicated research topic of choice.
ACHD Training Programs and Application Process
Currently, ACHD fellowship training is not accredited by Accreditation Council for Graduate Medical Education. Programs are currently in the midst of switching to a standard 2-year advanced fellowship, as outlined in the previous section. Accredited training is estimated to be uniformly available by July 1, 2019. Until that time, ACHD fellowship training must be affiliated with an accredited cardiology fellowship training program in the department (i.e., medicine or pediatrics), which sponsors the ACHD program.
There is a dearth of fellowship training programs for ACHD, with few graduates each year. The International Society for Adult Congenital Heart Disease maintains a web directory of programs offering formal fellowship training and is a good source for the applicant to obtain basic information about programs (2). According to this directory, there are 14 programs in United States offering formal training. Most of these programs offer 1 position per year. It is anticipated that this directory will be updated as more centers establish training programs. Another resource is the Adult Congenital Heart Association web site, which maintains a directory of ACHD clinics and programs that offer fellowship training (3). However, the duration of training in ACHD at programs listed at the Adult Congenital Heart Association varies widely and ranges from a few weeks' rotation within the context of general or pediatric cardiology training to 2-year dedicated ACHD fellowship training.
Considerations for the Applicant and Tips for Success
With limited opportunities for training, fellow-in-training at cardiology programs where formal training pathways are not available may lack the mentorship and exposure to this emerging field. Electives at ACHD training programs during general cardiology fellowship are strongly encouraged and may make applicants more competitive for an ACHD fellowship position.
Because many of these training programs are relatively new, the application process is not streamlined, and many are not formally advertised. Several available positions may get filled internally, and these may remain unknown to outside applicants. Contacting program directors directly and applying early in the academic year is advisable, as most programs finish applicant selection by December of the prior academic year.
Although applicants from either a pediatric or adult cardiology background can pursue training in ACHD according to the Accreditation Council for Graduate Medical Education, certain programs may have an inclination to accept applicants from a particular training background (pediatric, adult, or medicine/pediatrics). The reasons for this preference may not be entirely apparent to the applicant and can be related to source of funding, sponsoring department (adult cardiology vs. pediatric cardiology), and the specific design of the ACHD program. Although this program information may not be readily available, the applicants are advised to diligently evaluate profiles of previous graduates from the program and/or discuss with program directors.
Depending upon prior training background, the trainee may face different sets of challenges, and he or she should examine the location of the pediatric and adult hospital in relation to one another. For example, adult cardiology fellows may not be familiar with the anatomy of complex CHD and the palliative surgeries patients undergo during early infancy and childhood. Conversely, trainees with pediatric cardiology background may also not be familiar with management of late adult onset comorbidities, advanced heart failure, arrhythmias, and cardiology practice guidelines as they apply to adults. Proximity of the adult and pediatric hospitals to one another can enable trainees to fill in their knowledge gaps. Availability of video conferencing can help overcome some of the geographical limitations. The ACHD fellowship should be designed and customized to allow trainees from different backgrounds to overcome these challenges.
Life After Fellowship
After fellowship, most graduates join practices at large academic centers that serve as regional ACHD centers. Despite an expanding population of ACHD patients, finding a job that exclusively takes care of this patient population can be challenging, and a number of graduates practice a combination of pediatric cardiology or general adult cardiology and ACHD. This may change as more centers recognize the need to care for this growing complex patient population and develop ACHD programs with full-time dedicated ACHD specialists. Graduating fellows may join either an established ACHD program or assume a leadership position and develop a program of their own.
In conclusion, there has been a rapid expansion in the ACHD patient population that requires specialized care. The recent American Board of Medical Specialties accreditation of ACHD as a distinct subspecialty will provide an impetus for developing more training opportunities. As the training pathways evolve at various institutions, it is important that fellows from different backgrounds receive well-rounded training to have a successful career in this emerging subspecialty.
RESPONSE: Carpe Diem
In their article, Drs. Madan and Kim review the recent organizational advances for training in the care of adults with congenital heart disease (ACHD) and add insightful advice for fellows. Every program director desires such educated and empowered consumerism on the part of advanced cardiology fellows. To add, there is little to fear in the current appearance of complexity or uncertainty regarding ACHD training. I borrow from the ancient poet Horace, who reminds us, “Carpe diem,” or “seize the day” (1).
The prevalence of ACHD is likely markedly underestimated (consider bicuspid aortic valve disease/aortopathy and coronary artery anomalies each approximating 1%, with prevalence of more complex anatomic congenital heart disease ranging from 0.5% to 0.75%). As such, ACHD is present in the medical practices of every pediatrician, internist, primary care physician, and pediatric or internal medicine cardiologist. Unclear natural history and resource requirements for ACHD—combined with the perception of substantive burden of global cardiovascular disease, and improved outcomes when medical care is delivered in centers housing ACHD specialty clinics—has led to essentially unprecedented partnerships and support for advanced ACHD training and practice between primary care, pediatric, and internal medicine administrative leadership, advocacy, and care providers.
I underscore several points, all of which focus on the uniqueness of the present and its rich opportunities available to fellows-in-training (FIT) for ACHD training and practice:
1. Optimal care for ACHD of all complexity will not be a sole responsibility of ACHD subspecialty providers, but one that is shared between all those who medically support ACHD patients and families. Opportunity in education, research, care delivery methodology, and both quality and outcomes assessment abound.
2. The relative newness of many aspects of the ACHD field, combined with decades of advanced practice in some locales, allows for a phase of marked enthusiasm, transparency, dedication, volunteerism, and camaraderie. At present, pediatricians (PDs) not only act in the best interests of their regional clientele, but also look to develop process and personnel to deliver care and provide innovation throughout the country. Applicants for ACHD fellowship training who may not be optimally partnered in 1 or more ACHD training programs to which they applied are typically discussed among the PDs, and appropriate training (and practice) homes are found and can be offered to allow such individuals opportunities to grow and contribute to the field.
3. Hospitals and various health care practices increasingly recognize the need for cardiologists trained in ACHD care and those who have acquired critical experience and competencies. Although training and employment positions may appear few in number, almost every FIT who has desired to join an ACHD practice has found an appropriate home in which to do so, often with strong PD involvement in this process. Early, frequent, and insightful critique and guidance so as to encourage mastery of aspects of the career in which trainees most excel has been critical. Candidates should be aware that such mentoring may at times feel discouraging when the rebalancing of goals is suggested; yet, it is critical to successful long-term career accomplishment and personal satisfaction.
So, FITs interested in ACHD find themselves in a time of uncertainties of beginnings, but perhaps more so, in a time of abundance of alliance, mentorship, growth, and opportunity that allows for great satisfaction and accomplishment. To those who desire such an ACHD career, “carpe diem.”
- ↵Horace. Odes 1.11. 23 BC.
- American College of Cardiology Foundation
- Landzberg M.J.,
- Murphy D.J.,
- Davidson W.R.,
- et al.
- ↵International Society for Adult Congenital Heart Disease. ISACHD fellowship directory. Available at: http://www.isachd.org/fellowship. Accessed March 14, 2015.
- ↵Adult Congenital Heart Association. Adult congenital heart disease clinic directory. Available at: http://www.achaheart.org/home/clinic-directory.aspx. Accessed March 14, 2015.