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Abstract
Objectives This study aimed to determine the status of training of adult congenital heart disease (ACHD) cardiologists in Europe.
Methods A questionnaire was sent to ACHD cardiologists from 34 European countries.
Results Representatives from 31 of 34 countries (91%) responded. ACHD cardiology was recognised by the respective ministry of Health in two countries (7%) as a subspecialty. Two countries (7%) have formally recognised ACHD training programmes, 15 (48%) have informal (neither accredited nor certified) training and 14 (45%) have very limited or no programme. Twenty-five countries (81%) described training ACHD doctors ‘on the job’. The median number of ACHD centres per country was 4 (range 0–28), median number of ACHD surgical centres was 3 (0–26) and the median number of ACHD training centres was 2 (range 0–28). An established exit examination in ACHD was conducted in only one country (3%) and formal certification provided by two countries (7%). ACHD cardiologist number versus gross domestic product Pearson correlation coefficient=0.789 (p<0.001).
Conclusion Formal or accredited training in ACHD is rare among European countries. Many countries have very limited or no training and resort to ‘train people on the job’. Few countries provide either an exit examination or certification. Efforts to harmonise training and establish standards in exit examination and certification may improve training and consequently promote the alignment of high-quality patient care.
- EDUCATION
- Organizational Objectives
- Heart Defects, Congenital
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
High-quality training is important to ensure congenital cardiologists have the competencies to provide high-quality patient care.
In the USA, there is a standardised training for adult congenital heart disease (ACHD) trainees under the umbrella of the American Board of Internal Medicine with a well-established board examination.
In Europe, although there is high variation in the organisation, exit examination and certification of paediatric cardiology training, the landscape for ACHD remains unknown.
WHAT THIS STUDY ADDS
There is marked variation in the organisation, exit examination and certification of ACHD training across Europe.
Only 2 countries (7%) have formally recognised ACHD training programmes, 15 (48%) have informal training and 14 (45%) have very limited or no training programme. Most countries (25 (81%)) reported training ACHD doctors ‘on the job’.
Exit examination in ACHD was conducted in only one country (3%) and formal certification provided by two countries (7%).
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Several solutions are proposed, including harmonising training, standardising an exit examination and providing certification, which may help mitigate training variation, thereby promoting aligning high-quality patient care.
Introduction
Although there have been massive strides in congenital cardiac care over several decades, there remains a clear lack of standardisation and governance of training structures for congenital cardiology in Europe.1 2 Having recently highlighted the deficiencies in training of paediatric cardiologists across Europe and the need for a standardised curriculum and exit examination/certification, we must turn our attention to the status of training in adult congenital heart disease (ACHD).1–4 It is important to question what would represent a uniform standard against which training could be benchmarked across Europe. This should encourage quality, make equivalence more apparent and offer ACHD trainees to remain in Europe for their training, mitigating high staff turnover.5
The number of patients transitioning from paediatric to adult congenital services is increasing each year.6–8 In several countries, ACHD has now evolved as its own distinct specialty with several guidelines on management.6 9–12 ACHD training requirements in the USA are relatively standardised under the umbrella of the American Board of Internal Medicine (ABIM) with several guidelines endorsed by the American College of Cardiology and also the Canadian Cardiac Society.12–15 In the USA, there is a well-established board certification examination for ACHD to ameliorate gaps in training.13
Although some previous reports have studied and made recommendations for training of ACHD in Europe, there are limited data available on the structure and governance of ACHD training currently available.16–21 It is unknown which countries have an exit examination or certification. This study aimed to shed light on the current state of training of ACHD cardiologists, numbers of ACHD cardiologists per population for each European country, to elucidate which countries provide exit examinations and certification. The overarching aim is to encourage standardisation and provision of high-quality training, thereby promoting an equitable provision of high-quality expertise and healthcare to ACHD patients across Europe.
Methods and materials
Structured questionnaire and selection of countries
In September 2022, a structured questionnaire was prepared based on a previously conducted study.2 The questionnaire was reviewed with focus on completeness and clarity of the questions, length of time to complete the questionnaire and finally validated by Educational Committee of the Association of European Paediatric and Congenital Cardiology (AEPC). Questions were formulated to delineate the current training for all ACHD cardiologists throughout different training centres in Europe. Representative ACHD cardiologists from each country registered with the AEPC or identified through the AEPC Working Group on ACHD were invited by email to take part in the study. If the cardiologist declined to participate with repeated requests, the national AEPC delegate was asked then to nominate or recommend a substitute participant. If that person refused to participate after repeated efforts, then we deemed the country non-participatory. This study built on our previous training study2 by expanding the ACHD survey to 34 countries, extensively characterising training in those countries and offering bespoke solutions to training deficits.
The questionnaire (online supplemental appendix 1) detailed the number of training programmes, number of ACHD congenital cardiology trainees, trainee characteristics, curriculum, rotations, entry criteria, exit criteria and qualifications. Open-ended questions probed for strengths and weaknesses of current programmes. We asked the local cardiologist the number of ACHD patients, ACHD cardiologists and their estimation of the ‘ideal’ required number of ACHD cardiologists for their respective country.
Supplemental material
Definitions
‘Formal accredited or recognised training’ is defined as a nationally recognised (or accredited) structured training programme of sufficient standard to complete basic ACHD training to function as an independent ACHD cardiologist.
‘Informal training’ is defined as a programme being of sufficient standard to function independently as a consultant ACHD cardiologist. Of note, the training is not formally recognised (or accredited) irrespective of recognition by the Department of Health in that country.
‘ACHD cardiologist’ is defined as a medical doctor who fully completed ACHD cardiology training was appointed to a public hospital or clinic and actively delivered care as a specialist to adolescents or adults with congenital heart disease.
‘ACHD centre’ is defined as an established public clinic in a hospital caring for ACHD patients. ‘ACHD surgical centre’ was an established public hospital which provided surgical interventions for ACHD.
‘Competency-based medical education’ encapsulates education which focuses on fulfilling critical competencies the trainee must acquire to meet the healthcare needs of their patients (eg, the Canadian Medical Education Directive for Specialists.22
‘Gross domestic product’ (GDP) is the total value of all goods and services that are produced within a country’s borders during a specific time (2022 in this paper) (https://www.statista.com/statistics/685925/gdp-of-european-countries/).
Statistical analysis
Data were expressed as number (n), percentage (%), and median (minimum–maximum range). Median was chosen because most data refer to whole numbers and/or were asymmetrically distributed. Reporting minimum maximum range was preferred to make the outliers visible for the readers. Mainly descriptive statistics were applied. Population data were expressed against a number of ACHD cardiologists. GDP that can be used to compare the economic performance of different countries was correlated with the number of ACHD cardiologist to check whether the number of ACHD cardiologists would also be subject to economic prosperity. Pearson correlation statistics were applied. Statistical tests were two sided and a p<0.05 was considered to be statistically significant. Software packages that were used: Microsoft Office 365 and IBM SPSS Statistics V.28.0.
Results
Characteristics of the participating countries
Representatives from 31 out of 34 countries invited (91%) responded. Hungary, Serbia and Ukraine did not respond. ACHD cardiology was reported as recognised as a distinct specialty by the respective department of Health in two countries (7%) (table 1, figure 1).
Organisation of adult CHD training in Europe
ACHD cardiology subspecialty recognition by governmental ministries of health across 31 AEPC countries. Green represents countries whose Ministry of Health recognise ACHD cardiology as a distinct subspecialty. Red represents countries whose Ministry of Health do not recognise ACHD cardiology subspecialty. White represents a country which did not participate in the study. ACHD, adult congenital heart disease; AEPC, Association of European Paediatric and Congenital Cardiology.
Median number of ACHD patients per country was 18 687 (range 100–300 000). The median age of transition was 18 years (range 16–23 years age).
The median number of practising ACHD cardiologists was 9 (range 0–250) (table 2). The median estimated ‘required number’ of ACHD cardiologists was 15 (range 3–400). Twenty-seven (87%) countries reported a shortage of ACHD cardiologists.
ACHD cardiologists per million population and GDP In 31 European countries
The number of ACHD centres per country is presented in table 1. Looking at the distribution of centres, there was one ACHD cardiology centre per 2.69 million population (range 0.66–8.63 million), one ACHD training centre per 3.43 million population (range 0.66–21.8 million) and one ACHD surgical centre per 3.57 million population (range 1.25–9.34 million population). Paediatric and ACHD services were in the same centre in 6 countries, in separate centres in 20 and there was a mixture of both services in 5 countries. Nine countries reported ACHD patients remaining under care of paediatric cardiologists. Eighteen countries reported multiple hospitals caring for patients with ACHD.
ACHD training programmes in Europe
According to the countries that replied, two (7%) have formally accredited or recognised ACHD training programmes: Germany and the UK (online supplemental appendix 2). Fifteen (48%) have informal (not accredited or certified) training and 14 (45%) have very limited or no programme (figure 2). Twenty-five countries (81%) described training ACHD doctors ‘on the job’. The degree of informal training varies markedly with several countries reporting adult or paediatric trained cardiologists gravitating to ACHD care and ‘training on the job’ to take care of patients. Several countries reported very limited or no training programme (Bulgaria, Bosnia/Herzegovina, Croatia, Cyprus, Estonia, Greece, Iceland, Latvia, Poland, Portugal, Romania, Slovakia, Slovenia, Turkey) and scattered or very disorganised services with doctors having to emigrate to train in larger European centres. The broad variation in European training programmes is presented in table 1. The median number of training programmes per country was 2 (range 0–28). Approximately two-thirds allowed entry from either paediatric or adult cardiology. One-third required mandatory adult cardiology training. Only two countries (7%) matched training posts with the need for consultant ACHD cardiologists.
ACHD training programme status across 31 AEPC countries. Green represents a country with a formally recognised or accredited ACHD cardiology training programme. Blue represents a country with informal ACHD cardiology training programme. Red represents a country with very limited or no ACHD cardiology training programme. White represents a country which did not participate in the study. ACHD, adult congenital heart disease; AEPC, Association of European Paediatric and Congenital Cardiology.
The median number of ACHD fellows per training programme was 1 (range 0–3), and median duration of training was 1.75 years (range 1–5 years). Only two countries (7%) match training posts with postgraduate consultant cardiology posts. ACHD cardiologist number relation to nominal GDP correlation coefficient=0.789 (p<0.001) (figure 3).
Relationship of total number of ACHD cardiologists and gross domestic product (GDP) in Europe. ACHD, adult congenital heart disease.
Designed curriculum for ACHD training
Responses indicated that only six (19%) countries had a specifically designed curriculum, which was a written document in five countries (16%). The competencies expected of each trainee were delineated in five (16%) of these documents.
Structure of training
The answers of the questionnaire documented that in 4 countries (13%) there was both a national and local training director and in 12 countries there was a local fellowship director (39%). There was a specific design to training with increasing complexity of training through fellowship in eight countries. However, several respondents reported common challenges of training including lack of ACHD facilities, training structure and time to train (online supplemental appendix 3).
Breakdown of training exposure
Training in the countries surveyed included outpatient care (77%), inpatient care (88%), intensive care unit (50%), echocardiography (88%), cardiac catheterisation (67%), electrophysiology (40%), heart failure/transplantation/pulmonary hypertension (50%), advanced imaging (MRI/CT) (54%), preventive cardiology (40%) and pregnancy care (50%).
Exit examination and certification
Although only one country (3%) provided an exit examination, other countries provided regular assessments including work-based assessments, multisource feedback, consultant reviews and an ‘annual review of competence progression’ (eg, UK).
Only two countries (7%), Germany and the UK reported their country providing graduating trainees with formal certification/recognition of training in ACHD after completion of training (Zusatzbezeichnung Spezielle Kardiologie für Erwachsene mit angeborenen Herzfehlern and Certificate of Completion of Training)23 (online supplemental appendix 2).
Cardiovascular research during ACHD training
Fourteen respondents (45%) reported some form of research was encouraged during ACHD training (table 3). Only four respondents (13%) reported a dedicated formal time for research (median of 3 months, range 2–12 months). The majority of respondents (21/31, 68%) reported neither no dedicated time nor informal time dedicated to research.
Cardiovascular research during ACHD cardiology training among 31 European countries
ACHD trainee travel to other destination countries
Twenty-five respondents (81%) reported their trainees travel abroad for further training (table 4). The indications for travel abroad included limited training in their country (n=13), no subspecialist training (n=9), research (n=10) and to gain wider experience (n=15).
Foreign destinations for training by ACHD trainees from 31 AEPC countries
Training in transition care
In only 10 (32%) countries trainees received training on transition to adult services.
Regression on GDP
ACHD cardiologist number versus GDP correlation coefficient=0.789 (p<0.001) (figure 3).
Reception to improving governance, assessment and certification
All 31 (100%) respondents said they would welcome the introduction of an ACHD logbook. Twenty-nine (94%) respondents would welcome an exit examination and 30 (97%) would welcome the introduction of certification of completion of training.
Feedback on the questionnaire
Online supplemental appendix 4 summarises the feedback to this survey and lists suggestions on what to focus and how to proceed.
Discussion
This study reports a marked variation in training of ACHD fellows across Europe. Formal accredited or formally recognised training only occurs in a tiny minority of countries, clearly reflecting the significant potential for improvement in consistency of training and certification. Establishing a common curriculum with a single common examination set to a certain recognised level would be a start to improve consistency in training.
Each European country possesses a unique culture, language and often marked disparities in terms of resources and GDP. Such disparities are reflected in the wide variation in training patterns of ACHD cardiologists, not dissimilar to ACHD reports from the USA.14 15 This study demonstrated very few structured formalised training programmes, several with informal training (always without exit examination) and several with no formal training (usually but not necessarily in smaller countries with limited resources, eg, even resource replete countries such as Norway and Switzerland have limited training frameworks). Despite such a wide range of training programmes, many ACHD cardiologists are still ‘trained on the job’.
An unexpected finding from this study was the discovery that ACHD is recognised as a distinct specialty in only two countries (Germany and UK), thereby compromising the ability to develop a training framework in countries where ACHD specialty is not officially recognised. Furthermore in the UK, the Specialist Advisory Committee and the GMC both fail to recognise the specialty even though the Ministry of Health recognises it. A majority of countries had not even applied for subspecialist recognition. Some delegates reported that the Ministry of Health was tentative to provide recognition, even when requested, which may be related to funding issues. Similar findings were mentioned in the recently reported European paediatric cardiology study, which are stark findings when one considers that paediatric cardiology was recognised back in 1957 by the American Academy of Pediatrics and that board examination for paediatric cardiology certification and training programmes were established in 1961 and for ACHD by the ABIM in 2015 in the USA.7 20
Our aim in training ACHD cardiologists should be to provide them with the key competencies to be safe to work as independent doctors providing high-quality care to patients in their country. Such training can prove stressful for trainees even in well-structured programmes, hence it is critically important that the training provided be of high-quality and relatively standardised across Europe.24 Creative solutions in reducing stress may include novel instructional techniques (eg, echocardiography bootcamp or simulation), which can be easily incorporated into training at an early stage to allay some of these pressures on trainees.25 As well as matching training to the eventual daily roles of the cardiologist, ensuring those same cardiologists maintain their level of competence in line with evolving practice and innovation remains important.
Proposed solutions
The findings from this study highlight the continuing question of how we can improve ACHD training support for countries with limited resources. We propose the following initiatives (figure 4):
To support colleague countries lobbying their national department of Health for formal recognition of subspecialty status of ACHD. This is fundamental to providing a framework for training. Funding streams may need to be accessed to enable greater ACHD training and service development for some economically disadvantaged countries, given the recently reported disparities in resources.26
To harmonise the ACHD curriculum across Europe. This can replicate other specialties such as the Respiratory Medicine group (HERMES).27
To recommend standard ACHD fellowship duration (18 months to 2 years), rotations and expected levels of entrustment. We should direct our focus to high-quality training rather than simply counting the numbers of procedures. A logbook could record the quality of studies performed by the trainee. Recognising levels of entrustment provides an excellent model previously described for paediatric cardiology trainees.2
Most larger countries can offer basic level core ACHD fellowship training.
Foster collaborations between smaller countries with limited training support and larger better resourced countries with a track record in training ACHD cardiologists. Potential hubs of training, some partly in situ already, could be established between different countries. For example, a Nordic block (cumulative population exceeding 27 million) for training in ACHD cardiology similar to that proposed for paediatric cardiology.2 Alternatively, trainees from smaller countries with limited resources could benefit from an exchange programme undertaking elective periods (similar to the Erasmus secondary school scholarship) at larger better resourced ACHD centres to supplement their training.
AEPC and European Society of Cardiology (ESC) as European governing structures can foster the development of such partnerships.
Provide a common exit knowledge based ACHD assessment and certification which would facilitate transfer of professional qualifications across different countries.
The AEPC education group and the ESC can collaborate further and offer courses to educate trainers in instructional design and novel learning techniques.
Encourage broader adoption of novel strategies including online learning, for example, webinars (‘Heart University’, ‘Heartbeats’ webinars, ‘Congenital Heart Academy’ and ‘World University for Paediatric and Congenital Heart Surgery’).28
AEPC and ESC can host educational sessions, for example, webinars29 and specific sessions at research meetings.
Support ACHD research collaboration across Europe30 and promote research into training of ACHD cardiologists. Funding sources should be explored to invest in the education and training of ACHD specialists.
Strategies for improving the education and training of adult congenital heart disease cardiologists in Europe. These include subspecialty recognition by each countries Ministry of Health (1), standardisation of curriculum development for ACHD across Europe (2), develop a common exit examination (3) and certification for ACHD (4), develop partnerships between larger and smaller countries/centres to promote ACHD training (5), ongoing collaboration between ESC and AEPC organisations to foster these initiatives (6), greater communication and collaboration through online meetings (7), greater research collaboration between ACHD centres in Europe (8), increased funding support for education and training of ACHD specialists (9). ACHD, adult congenital heart disease; AEPC, Association of European Paediatric and Congenital Cardiology.
These proposals will require dialogue and planning involving official working groups under the AEPC and ESC umbrella. This paper should not be just a box-ticking exercise but an impetus for implementation of real change and learning benefits for ACHD trainees.
Where to now?
Reflecting on the sobering results of this study, we must go further and ask the question should all European ACHD cardiologists be specifically formally trained in this area or do we wish to continue the current practice of having non-specialist cardiologists practising in this field? In 2023, surely the time has come to expect the ACHD field to be respected as its own entity, with proper expectations of training and certification standards. Universal training standards have been advocated by other European groups (Harmonisation of Education in Respiratory Medicine for European Specialists, hermes.ersnet.org) demonstrating improved standards of knowledge.27 How ACHD training centres of excellence would be developed remains to be decided. However, it would seem logical if ACHD trainees receive structured high-quality training that this expertise would reach and benefit ACHD patients. USA and Canada launched already in 2015 an urgent call ‘to strengthen and standardise ACHD training to meet the increasing workforce requirements of this population’31 and they started to develop structured training programmes stating that ‘advanced physician training for ACHD in the past 10 years, have begun to improve disease outcomes’.32
Limitations of the study
Despite a high participation rate in this study, some countries’ ACHD physicians could not be enrolled. Not every respondent was able to provide a complete data set for all the studied variables. We relied on each respondent to provide accurate data for their country including the number of patients and ACHD cardiologists. Most countries do not have a national registry of every ACHD patient so the number of ACHD patients were estimated by the respondents. There clearly is the potential for bias and possible error as this is somewhat subjective process. However, in an effort to ensure data accuracy, we requested the respondent from each country to carefully review the finalised paper. Statistics relating to the ratio of patients to ACHD cardiologists may be estimated as the exact number of ACHD cardiologists may be difficult to measure for every country. Also survival of congenital cardiac patients to adulthood may vary between countries, directly impacting the potential need for ACHD cardiologists. The differentiation between informal training and ‘training on the job’ can prove a challenge and there are nuances in training in specific countries. Small private practice institutions were not included in this study.
Conclusion
In conclusion, ACHD cardiology education and training varies markedly across Europe. This paper not only maps the training landscape but proposes initiatives towards a more standardised and organised approach, with the aim of promoting better trained ACHD cardiologists. Through collaboration to support pan European solutions which can be implemented and sustained, we can promote excellence in ACHD training. Hopefully better trained doctors will facilitate increased ACHD expertise improving patient care across the entire continent.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Approval of the above study was waived from the Ethics Department at CHI Children’s Health Ireland, Crumlin, Dublin Ireland.
Acknowledgments
We are grateful to the AEPC council, the AEPC ACHD working group and the AEPC educational committee for their support in undertaking this project. We are grateful to Drs D. Tobler, P. Hoffman, T. Zatocil, A. Strenge, I. Simkova and all the individuals who helped to complete the survey or directed us to the correct person to complete the survey. Ms Linda Bosschers provided enormous assistance in finalising questionnaires and coordinating the project. Mr Andrew Pendred generated the maps. Ms Myrthe Boymans created the central illustration.
References
Supplementary materials
Supplementary Data
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Footnotes
Twitter @Mag_Ladouceur
Contributors All authors contributed data, reviewed the manuscript, edited the manuscript and assisted with revisions. CJM and WB conceived the study and designed the study. CJM designed the survey. CJM collated data, wrote the first draft and submitted the manuscript and revisions of the manuscript. WB edited and reviewed the final version of the manuscript. IV collated data, edited and assisted in the revision of the manuscript. PJ collated data, edited and assisted in the revision of the manuscript. MB collated data, edited and assisted in the revision of the manuscript. PPB collated data, edited and assisted in the revision of the manuscript. KW collated data, edited and assisted in the revision of the manuscript. PFC collated data, edited and assisted in the revision of the manuscript. SA collated data, edited and assisted in the revision of the manuscript. MC collated data, edited and assisted in the revision of the manuscript. ML collated data, edited and assisted in the revision of the manuscript. OM collated data, edited and assisted in the revision of the manuscript. MAG collated data, edited and assisted in the revision of the manuscript. OP collated data, edited and assisted in the revision of the manuscript. MR assisted in statistical analysis, generated correlation graph and edited the manuscript. DCA-B collated data, edited and assisted in the revision of the manuscript. SS collated data, edited and assisted in the revision of the manuscript. AEvdB collated data, edited and assisted in the revision of the manuscript. MD collated data, edited and assisted in the revision of the manuscript. RH collated data, edited and assisted in the revision of the manuscript. JIS collated data, edited and assisted in the revision of the manuscript. BG collated data, edited and assisted in the revision of the manuscript. SM-D collated data, edited and assisted in the revision of the manuscript. KP collated data, edited and assisted in the revision of the manuscript. IM-B collated data, edited and assisted in the revision of the manuscript. LG collated data, edited and assisted in the revision of the manuscript. RT collated data, edited and assisted in the revision of the manuscript. AP collated data, edited and assisted in the revision of the manuscript. M-EE collated data, edited and assisted in the revision of the manuscript. MJ collated data, edited and assisted in the revision of the manuscript. ISP collated data, edited and assisted in the revision of the manuscript. DN collated data, edited and assisted in the revision of the manuscript. GD collated data, edited and assisted in the revision of the manuscript. AJ collated data, edited and assisted in the revision of the manuscript. TK collated data, edited and assisted in the revision of the manuscript. GO collated data, edited and assisted in the revision of the manuscript. AF collated data, edited and assisted in the revision of the manuscript. CMM is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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