JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 65, NO. 20, 2015

ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jacc.2015.04.002

FELLOWS-IN-TRAINING & EARLY CAREER PAGE

Training in Adult Congenital Heart Disease Pankaj Madan, MD,* Yuli Y. Kim, MDy

S

urgical and medical advances over the past few

adult or pediatric cardiology fellowship, ACHD

decades have now enabled >90% of children

fellowship training is a 24-month commitment, in-

born with congenital heart disease (CHD) to

cluding 18 months of full-time clinical training and

survive until adulthood. Current estimates indicate

6 months of elective clinical or research experience.

that there are now more adults with CHD than chil-

Guidelines specify that during the 2-year training

dren, with approximately 1.3 million adults living in

program, the trainee should spend 9 to 12 months on

the United States alone. In response to an increasing

inpatient service and/or ACHD consultative service;

population of affected adults, adult congenital heart

3 months in ACHD imaging, including echocardiog-

disease (ACHD) as a specialty was recognized in

raphy and cardiac magnetic resonance imaging;

1990, and in 2001, the 32nd Bethesda Conference rec-

2 months in cardiac catheterization of the ACHD

ommended that care be delivered to this complex

patient; and 1 month in the intensive care unit caring

patient population by ACHD specialists in dedicated

for post-operative patients. Trainees with pediatric

ACHD centers (1). There are, however, inadequate

cardiology backgrounds should spend 2 months

numbers of such specialists, and we are currently

taking care of general adult cardiology inpatients, and

faced with a dire workforce shortage to care for this

those from an adult cardiology training background

growing population.

should spend 2 months caring for pediatric CHD

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

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.

American Board of Pediatrics in pediatric cardiology.

ACHD TRAINING PROGRAMS AND

To become certified in the subspecialty of ACHD,

APPLICATION PROCESS

trainees must complete ACHD fellowship training and pass the board certification examination, which will

Currently, ACHD fellowship training is not accredited

be offered for the first time in 2015 and every other

by Accreditation Council for Graduate Medical Edu-

year thereafter.

cation. Programs are currently in the midst of

Trainees may have a background in internal med-

switching to a standard 2-year advanced fellowship,

icine, pediatrics, or combined residency training in

as outlined in the previous section. Accredited

internal medicine and pediatrics. After completion of

training is estimated to be uniformly available by July 1, 2019. Until that time, ACHD fellowship training must be affiliated with an accredited cardiology

From the *Newark Beth Israel Medical Center and Children’s Hospital of

fellowship training program in the department (i.e.,

New Jersey, Newark, New Jersey; and the yChildren’s Hospital of

medicine or pediatrics), which sponsors the ACHD

Pennsylvania/University of Pennsylvania, Philadelphia, Pennsylvania.

program.

Madan and Kim

JACC VOL. 65, NO. 20, 2015 MAY 26, 2015:2254–6

There is a dearth of fellowship training programs for ACHD, with few graduates each year. The Inter-

Fellows-in-Training & Early Career Page

profiles of previous graduates from the program and/ or discuss with program directors.

national Society for Adult Congenital Heart Disease

Depending upon prior training background, the

maintains a web directory of programs offering

trainee may face different sets of challenges, and he

formal fellowship training and is a good source for the

or she should examine the location of the pediatric

applicant to obtain basic information about programs

and adult hospital in relation to one another. For

(2). According to this directory, there are 14 programs

example, adult cardiology fellows may not be familiar

in United States offering formal training. Most of

with the anatomy of complex CHD and the palliative

these programs offer 1 position per year. It is

surgeries patients undergo during early infancy

anticipated that this directory will be updated as

and childhood. Conversely, trainees with pediatric

more centers establish training programs. Another

cardiology background may also not be familiar

resource is the Adult Congenital Heart Association

with management of late adult onset comorbidities,

web site, which maintains a directory of ACHD

advanced heart failure, arrhythmias, and cardiology

clinics and programs that offer fellowship training

practice guidelines as they apply to adults. Proximity

(3). However, the duration of training in ACHD

of the adult and pediatric hospitals to one another can

at programs listed at the Adult Congenital Heart

enable trainees to fill in their knowledge gaps.

Association varies widely and ranges from a few

Availability of video conferencing can help overcome

weeks’ rotation within the context of general or

some of the geographical limitations. The ACHD

pediatric cardiology training to 2-year dedicated

fellowship should be designed and customized to

ACHD fellowship training.

allow trainees from different backgrounds to over-

CONSIDERATIONS FOR THE

come these challenges.

APPLICANT AND TIPS FOR SUCCESS

LIFE AFTER FELLOWSHIP

With limited opportunities for training, fellow-

After fellowship, most graduates join practices at large

in-training at cardiology programs where formal

academic centers that serve as regional ACHD centers.

training pathways are not available may lack the

Despite an expanding population of ACHD patients,

mentorship and exposure to this emerging field.

finding a job that exclusively takes care of this patient

Electives at ACHD training programs during general

population can be challenging, and a number of

cardiology fellowship are strongly encouraged and

graduates practice a combination of pediatric cardiol-

may make applicants more competitive for an ACHD

ogy or general adult cardiology and ACHD. This may

fellowship position.

change as more centers recognize the need to care for

Because many of these training programs are rela-

this growing complex patient population and develop

tively new, the application process is not streamlined,

ACHD programs with full-time dedicated ACHD

and many are not formally advertised. Several avail-

specialists. Graduating fellows may join either an

able positions may get filled internally, and these may

established ACHD program or assume a leadership

remain unknown to outside applicants. Contacting

position and develop a program of their own.

program directors directly and applying early in

In conclusion, there has been a rapid expansion in

the academic year is advisable, as most programs

the ACHD patient population that requires special-

finish applicant selection by December of the prior

ized care. The recent American Board of Medical

academic year.

Specialties accreditation of ACHD as a distinct sub-

Although applicants from either a pediatric or adult

specialty will provide an impetus for developing more

cardiology background can pursue training in ACHD

training opportunities. As the training pathways

according to the Accreditation Council for Graduate

evolve at various institutions, it is important that

Medical Education, certain programs may have an

fellows from different backgrounds receive well-

inclination to accept applicants from a particular

rounded training to have a successful career in this

training background (pediatric, adult, or medicine/

emerging subspecialty.

pediatrics). The reasons for this preference may not be entirely apparent to the applicant and can be

REPRINT REQUESTS AND CORRESPONDENCE: Dr.

related to source of funding, sponsoring department

Pankaj Madan, Center for Adult Congenital Heart

(adult cardiology vs. pediatric cardiology), and the

Disease, Newark Beth Israel Medical Center and

specific design of the ACHD program. Although this

Children’s Hospital of New Jersey, 201 Lyons Avenue,

program information may not be readily available,

Newark, New Jersey 07112. E-mail: pankajmadanmd@

the applicants are advised to diligently evaluate

gmail.com.

2255

2256

Madan and Kim

JACC VOL. 65, NO. 20, 2015 MAY 26, 2015:2254–6

Fellows-in-Training & Early Career Page

REFERENCES 1. Landzberg MJ, Murphy DJ, Davidson WR, et al. Task force 4: organization of delivery systems for adults with congenital heart disease. J Am Coll Cardiol 2001;37:1187–93.

2. International Society for Adult Congenital Heart Disease. ISACHD fellowship directory. Available at: http://www.isachd.org/fellowship. Accessed March 14, 2015.

3. Adult Congenital Heart Association. Adult congenital heart disease clinic directory. Available at: http://www.achaheart.org/home/clinicdirectory.aspx. Accessed March 14, 2015.

RESPONSE: Carpe Diem Michael J. Landzberg, MD Boston Children’s Hospital, Boston, Massachusetts E-mail: [email protected] In their article, Drs. Madan and Kim review the recent orga-

2. The relative newness of many aspects of the ACHD

nizational advances for training in the care of adults with

field, combined with decades of advanced practice in

congenital heart disease (ACHD) and add insightful advice

some locales, allows for a phase of marked enthu-

for fellows. Every program director desires such educated

siasm, transparency, dedication, volunteerism, and

and empowered consumerism on the part of advanced

camaraderie. At present, pediatricians (PDs) not only

cardiology fellows. To add, there is little to fear in the current

act in the best interests of their regional clientele, but

appearance of complexity or uncertainty regarding ACHD

also look to develop process and personnel to deliver

training. I borrow from the ancient poet Horace, who re-

care and provide innovation throughout the country.

minds us, “Carpe diem,” or “seize the day” (1).

Applicants for ACHD fellowship training who may not

The prevalence of ACHD is likely markedly under-

be optimally partnered in 1 or more ACHD training

disease/

programs to which they applied are typically dis-

aortopathy and coronary artery anomalies each approxi-

cussed among the PDs, and appropriate training (and

mating 1%, with prevalence of more complex anatomic

practice) homes are found and can be offered to allow

congenital heart disease ranging from 0.5% to 0.75%). As

such individuals opportunities to grow and contribute

estimated

(consider

bicuspid

aortic

valve

such, ACHD is present in the medical practices of every pediatrician, internist, primary care physician, and pedi-

to the field. 3. Hospitals

and

various

health

care

practices

atric or internal medicine cardiologist. Unclear natural

increasingly recognize the need for cardiologists

history and resource requirements for ACHD—combined

trained in ACHD care and those who have acquired

with the perception of substantive burden of global car-

critical experience and competencies. Although

diovascular disease, and improved outcomes when med-

training and employment positions may appear

ical care is delivered in centers housing ACHD specialty

few in number, almost every FIT who has desired

clinics—has led to essentially unprecedented partnerships

to join an ACHD practice has found an appropriate

and support for advanced ACHD training and practice

home in which to do so, often with strong PD

between primary care, pediatric, and internal medicine

involvement in this process. Early, frequent, and

administrative leadership, advocacy, and care providers.

insightful critique and guidance so as to encourage

I underscore several points, all of which focus on the

mastery of aspects of the career in which trainees

uniqueness of the present and its rich opportunities

most excel has been critical. Candidates should be

available to fellows-in-training (FIT) for ACHD training

aware that such mentoring may at times feel

and practice:

discouraging when the rebalancing of goals is

1. Optimal care for ACHD of all complexity will not be a sole responsibility of ACHD subspecialty pro-

suggested; yet, it is critical to successful long-term career accomplishment and personal satisfaction.

viders, but one that is shared between all those

So, FITs interested in ACHD find themselves in a time of

who medically support ACHD patients and fam-

uncertainties of beginnings, but perhaps more so, in a time of

ilies. Opportunity in education, research, care

abundance of alliance, mentorship, growth, and opportunity

delivery methodology, and both quality and out-

that allows for great satisfaction and accomplishment. To

comes assessment abound.

those who desire such an ACHD career, “carpe diem.”

REFERENCE 1. Horace. Odes 1.11. 23 BC.