PAEDIATRIC CARDIOLOGY 

DEFINITION:Pediatric cardiology is that branch of medicine concerned with the study of congenital and acquired heart disease in the fetus, newborn, child and young adult.

GENERAL OBJECTIVES:Residents must demonstrate the knowledge, skills and attitudes relating to gender, culture and ethnicity pertinent to pediatric cardiology. On completion of the educational program, the graduate physician will be competent to function as a consultant in pediatric cardiology. This requires the physician to:

• Provide scientifically based, comprehensive and effective diagnosis and management for patients with disorders of the cardiovascular system;
• Communicate effectively with families, children and referring physicians as well as other health care professionals;
• Counsel patients, families and others on aspects of prevention of disorders related to pediatric cardiology, including risk factors and genetic and environmental concerns;
• Maintain complete and accurate medical records;
• Effectively coordinate the work of the health care team;
• Be an effective teacher of other physicians (including medical students and specialty residents), and other health care personnel and patients;
• Be proficient in professional and technical skills related to the specialty;
• Demonstrate personal and professional attitudes consistent with a consultant physician role;
• Be willing to and able to appraise accurately his or her own professional performance;
• Be willing and able to keep his or her practice current through reading and other modes of continuing medical education;
• Be able to critically assess the cardiovascular/cardiological literature as this pertains to patient diagnosis, investigation and management; and
• Be able to participate in clinical or basic science studies as a member of the research team.

These elements of competence are expanded as detailed objectives, for greater clarity, in the following pages. The terms "effective" and "appropriate" are used frequently in these statements. "Effective" is defined for the purpose of this document as "adequate to the efficient solution of the problem". "Appropriate" is defined as "appropriate to the presenting problem(s) and patient attitudes and activity". Throughout this document, the term "cardiovascular/cardiological" is understood to refer to the cardiovascular system, and the peripheral vascular system, the innervation and/or neurohumoral control and regulation of cardiac function, and hormonal and/or pharmacological influences as these may relate to the cardiovascular system.

The detailed objectives describe minimal standards, and in no way exclude the necessity for mastery of additional knowledge, skills or attitudes necessary for the most effective management of patients with cardiovascular system disorders.

SPECIFIC OBJECTIVES:

Medical Expert/Clinical Decision-Maker

General Requirements

• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal opinions.

Specific Requirements
Provide scientifically based, comprehensive and effective diagnosis and management for infants and children with cardiovascular disorders. In order to achieve these objectives, the residents must be able to attain the following clinical skills, technical skills and knowledge.

1. Clinical Skills

For a patient with cardiovascular complaint or disorder, the residents will be able to:

• Obtain a complete cardiovascular history from older children and families obtaining additional information from health care personnel where indicated;
• Perform an appropriate physical examination;
• Determine whether the patient's symptoms and signs are the results of a cardiovascular disorder or a problem with some other system. The residents must determine and/or exclude the heart as the source of the patient's concerns;
• Formulate an appropriate differential and provisional diagnosis;
• Outline an appropriate plan of laboratory investigation;
• Outline an appropriate therapeutic plan; and
• Exhibit appropriate clinical judgment in outlining a differential diagnosis and an investigative and therapeutic plan, taking into account matters such as the patients age, other health risks, risk and cost of investigations, risk and cost of therapies, the epidemiology of the disease process, and the long-term prognosis for complex lesions.

2. Technical Skills

• Perform and interpret an electrocardiogram (ECG) in all of its iterations, such as resting and exercise ECG's, Holter studies, atrial and esophageal wire studies.
• Perform and interpret an echocardiogram in the many standard formats, including m-mode, two dimensional and color Doppler, spectral Doppler and also including transesophageal studies and fetal echocardiography.
• Perform and interpret cardiac catheterization including the correct patient selection, entry site and techniques, manipulation and choice of catheters, the acquisition of accurate and reliable hemodynamic data and the interpretation of such data. The appropriate application of ionizing irradiation and a knowledge of the safety measures implicit in performing procedures that involve catheterization and ionizing radiation.
• Understand the indication and application of therapeutic catheterization in all of its forms.
• Understand the indications for and use of exercise testing including pharmacologic stress testing.
• Understand the indications and utility of nuclear imaging as such may apply to cardiovascular disease.
• Understand the indications and utility of intracardiac electrophysiologic testing, and the indications for application of intracardiac therapy for arrhythmias.
• Understand the indications for and interpretation of specialized imaging techniques as they may be applied in the practice of pediatric cardiology, such as magnetic resonance imaging scans, computerized tomography techniques, and the indications for position emission tomography (PET) scans.
• Understand the embryology of a normal heart, and the many variables that are associated with maldevelopment of the heart.
• Observe and review a cardiac specimen identifying appropriately all cardiac chambers and related structures to arrive at an appropriate pathological diagnosis.

3. Knowledge

As a basis for clinical competence, the pediatric cardiologists must be familiar with and able to describe or discuss:

• The clinical features, including presenting signs and symptoms, natural history, and prognosis, for all major structural/acquired heart diseases.
• The clinical course of diseases in related organ systems that may impact upon heart disease including pulmonary, renal, hepatic and others.
• The embryological development of the cardiovascular system and how congenital anomalies arise from disorders of this process.
• The gross and microscopic anatomy of the cardiovascular system, the associated vascular trunks, muscular and fibrous supports.
• The anatomy, composition and physiology of the cardiac muscle cell.
• The mechanism underlying the resting membrane potential, conduction of an action potential and transmission of electrical stimuli through the myocyte.
• Ion transport within the cell.
• The cardiac enzymes, their interaction, the distribution and timing of cardiac enzymes with myocardial injury.
• The anatomy, function and disorders of the pericardium.
• Coronary arterial flow and oxygen delivery to the myocytes.
• Disorders of coronary arterial formation, position and distribution which may lead to myocardial ischemia.
• Abnormalities and disorders of the immune system and infectious processes which may influence the myocardium or vascular system.
• The role of exercise in changing cardiac physiology.
• The influence of teratogens on development of the fetal heart, including pharmacologic, infectious processes etc.
• Indications, mechanisms of action and the side effects of medications used in the therapy of cardiac disorders.
• The role of a healthy lifestyle in the prevention of cardiovascular disease including the role of smoking, lipids, diet and exercise.
• The role and influence of heredity, disorders of the gene and other biochemical and metabolic disturbances which may influence cardiac development and/or function.
• The influence of therapies for other medical conditions, such as malignancies, which may have important secondary effects on myocardial function.
• The role of cardiac transplantation and other myocardial support devices in the treatment of end-stage cardiac failure.
• How to trouble shoot various types of cardiac pacemakers.

Communicator

General Requirements

• Establish therapeutic relationships with patients, families of infants and children with cardiovascular disorders.
• Obtain and synthesize relevant history from patients, families and their communities.
• Listen effectively.
• Discuss appropriate information with patients, families and the health care team.

Specific Requirements

Communicate effectively with patients, their families and medical colleagues (particularly referring physicians), and other healthcare professionals. In order to achieve these objectives, the residents must develop the ability to:

• Communicate effectively and regularly with patients and their families.
• Be considerate and compassionate in communications with patients and families, and to provide accurate information appropriate to the clinical situation, with a reasonable attempt at prognosis.
• Communicate effectively with medical colleagues, including referring physicians, in both the in-patient and outpatient settings.
• Communicate effectively and appropriately with nurses and paramedical personnel.
• Ensure there has been adequate communication about the patient with the person who will actually be doing and/or reporting the diagnostic study, when ordering investigative procedures.

Counsel patients and others about aspects of prevention of cardiovascular disorders, including risk factors, and genetic and environmental concerns. In order to achieve these objectives, the resident must develop the ability to:

• Recognize that complete patient care requires a correct diagnosis as well as a search for risk factors for the disorder.
• Recognize that treatment for a patient with a cardiovascular disorder may require in addition to specific medical and surgical interventions, the elimination of risk factors and genetic counseling.

Collaborator

General Requirements

• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.

Specific Requirements

Be an effective teacher of other physicians (including medical students and specialty residents), other healthcare personnel, and patients. In order to achieve these objectives, the residents must develop the ability to:

• Provide instruction to medical students and more junior physicians at a level appropriate to their clinical education and professional competence.
• Willingly share knowledge with others with whom they are associated, thus ensuring the most effective delivery of healthcare to patients.

Manager

General Requirements

• Utilize resources effectively to balance patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care, life-long learning and other activities.

Specific Requirements

 
In order to achieve these objectives, the residents must develop the ability to:

• Be proficient in professional skills related to the specialty.
• Demonstrate the following professional skills in time management including to: recognize that effective use of time depends upon punctuality and requires planning; develop speed as well as accuracy in clinical skills; reserve time for reading and keeping current with the cardiovascular literature; and establish routines for carrying out regular activities and adhere to them.
• Maintain complete and accurate medical records. The residents will record and maintain a complete and accurate medical record for every patient seen. This record will include the patient's history and findings on physical examination (including the cardiac system examination) a differential diagnosis, a provisional diagnosis, a plan for management, appropriate progress notes, and a comprehensive discharge summary.
• Coordinate the work of the health care team including organizing and supervising the more junior physicians and medical students on a ward and/or consultation service in a manner that ensures the efficient and effective delivery of healthcare for the patients; indicating by the treatment plan that, for the optimal treatment of many patients with cardiac disorders, a team approach is necessary; members of the team may include nurses, rehabilitation personnel (physiotherapists, occupational therapists, psychologists, social workers and those who would provide respite care for the family); and identifying where an important role can be played by disease focused family/lay groups with regard to helping the patient and/or family and to facilitate their recovery and coping.

Health Advocate

General Requirements

• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements

 
In order to achieve these objectives, the residents must:

• Learn about community resources and related patient support groups; provide assistance to access programs (such as home oxygen, home medication provisions, occupational health and physiotherapy, drug plans) and participate in the activities with their patients.
• Educate, to generate and access information (such as printed material, video assisted learning, Internet assisted learning) and to be available as a resource person to counsel patients and families effectively on cardiovascular disorders.
• Counsel patients and their families in understanding the disease processes from which they suffer, and to understand the potential for future manipulation/intervention to improve their well-being. Similarly, families and patients must recognize the role of preventative health care in their personal well-being.
• Understand the role of national and international bodies in the promotion of cardiovascular health, and the prevention, detection and treatment of cardiac disorders.

Scholar

General Requirements

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Facilitate learning of patients, housestaff/students and other health professionals.
• Contribute to development of new knowledge.

Specific Requirements

In order to achieve these objectives, the residents must:

• Critically assess the cardiovascular literature as it relates to patient diagnosis, investigation and treatment including developing criteria for evaluating the cardiovascular literature; and critically assessing the cardiovascular literature using these criteria.
• Participate in clinical and/more basic science studies as members of a research team, including being able to describe principles of good research; and using the above principles to judge whether a research project is properly designed.

Professional

General Requirements

• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practise medicine ethically consistent with obligations of a physician.

Specific Requirements

In order to achieve these objectives, the residents must develop the ability to:

• Demonstrate personal and professional attitudes consistent with a consulting physician role, including periodical review of their own personal and professional performance against national standards set for the specialty; being willing to include the patient and family in discussions concerning appropriate diagnostic and management procedures; showing appropriate respect for the opinions of fellow consultants and referring physicians in the management of patient problems and to be willing to provide means whereby differences of opinion can be discussed and resolved.
• Appraise accurately their own professional performance. The residents will show that they recognize their own limitations with regard to skill and knowledge by appropriately consulting other physicians and paramedical personnel when caring for the patient.
• Keep their practice current through reading and other modes of continuing medical education. The residents will develop a habit of maintaining current clinical skills and knowledge base through continuing medical education.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in pediatric cardiology must be consistent with the specialty training requirements.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in pediatric cardiology.

In those cases where a university has sufficient resources to provide most of the training in pediatric cardiology but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

1. Teaching Faculty

There must be a sufficient number of qualified and dedicated teaching staff to supervise residents at all levels and in all aspects of pediatric cardiology, and provide teaching in the basic and clinical sciences related to cardiology.

2. Number and Variety of Patients

There must be a sufficient number and variety of patients available to the program to provide each resident registered in the program extensive opportunity for exposure to major cardiac diseases seen in the pediatric age group, including congenital heart disease, valvular heart disease, rheumatic heart disease, pericardial heart disease, cardiomyopathy, arrhythmia, congenital heart disease in adults and congestive heart failure. The following specific objectives should be met:

1. Catheterization Laboratory: to assure broad experience and training, the yearly case load should approximate a minimum of 125 cases, of which at least 50 should be on patients less than one year of age and should include at least 15 interventional cases, excluding balloon atrial septostomies;
2. Cardiac Surgery: a minimum of 75 open extra-corporeal circulatory procedures on infants and children. Approximately 25 of these open heart procedures should be performed on patients less than one year of age to assure experience and involvement in the selection of patients for cardiac surgery and post-operative cardiac care.

3. Clinical Services Specific to Pediatric Cardiology

The physical and technical resources available to the program must be adequate to meet the needs of the program.

There must be:

1. an active clinical teaching service in pediatrics;
2. Laboratories appropriately organized for teaching and dedicated to:
   1. cardiac catheterization - a fully equipped and staffed biplane angiographic laboratory organized for instruction in catheter techniques and the calculation and interpretation of hemodynamic data, under supervision of a qualified cardiologist;
   2. echocardiography - a facility with staff knowledgeable and trained in the use of M-mode and cross-sectional echocardiography, Doppler, transesophageal and fetal techniques;
   3. electrophysiology/pacemaker - a facility for the insertion, management and assessment of pacemakers organized for instruction in pacemaker application; an electrophysiologic laboratory capable of instruction in the principles of intracardiac and extracardiac pacing and recording;
   4. electrocardiography - a graphics laboratory with facilities for recording a standard 12 lead ECG, with 24-hour ambulatory capability;
   5. exercise testing;
3. ambulatory care facilities to provide residents with experience in the broad range of non-hospitalized patients with cardiac problems. In-patient and out-patient services should be integrated as much as possible to provide continuity of observation both in and out of hospital. Organized clinics must provide opportunities for pre-admission investigations and post-discharge follow-up. This should include postoperative surgical follow-up. It is essential that regularly scheduled clinics be supervised by one or more members of the cardiology staff and provide a teaching milieu which permits longitudinal follow-up and continuity in patient care. The schedules of residents are to be so arranged as to ensure their availability and attendance;
4. a consultation service to provide experience in elective and emergency consultations in patients with cardiac diseases;
5. facilities and services involved in assessment of the fetus including echocardiography;
6. cardiology patient data base to facilitate the review of clinical activity and quality of care in the department.

4. Supporting Services — Clinical, Diagnostic, Technical

There must be:

1. a department of radiology - with access to newer imaging techniques including:
   1. magnetic resonance imaging
   2. computerized tomography;
2. an active clinical and teaching service in cardiac surgery. There must be regularly scheduled combined cardiac surgery conferences for evaluation, review and discussion of patient management with the surgical staff. The operating room should be designed and equipped for cardiopulmonary extracorporeal circulation with appropriate monitoring devices, defibrillator and cardiac pacing devices;
3. an active clinical teaching service in adult cardiology;
4. a Department of Pathology - able to provide gross anatomical, histological, biochemical and microbiological services for the study of cardiovascular problems;
5. a respiratory medicine service with a pulmonary function laboratory;
6. other services in support of the program including neonatology, genetics, immunology, nutrition, psychology and biomedical electronics;
7. an Emergency Department to provide each pediatric cardiology resident with opportunities to provide an initial assessment and consultative service to patients presenting with emergency cardiac conditions;
8. an Intensive Care Unit, organized to provide experience in the care of the critically ill non-surgical and surgical pediatric patient with cardiovascular disease;
9. an Intensive Care Nursery, organized to provide experience in the management of the critically ill premature and mature newborn, an understanding of the transitional circulation and an exposure to fetal monitoring and echocardiographic assessment;
10. university expertise in basic sciences related to cardiology.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will, in part be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice. Service demands must not seriously interfere with the ability of the residents to follow the academic program.

The educational program must provide opportunities for residents to learn and demonstrate:

1. Knowledge of anatomy, embryology, physiology, electrophysiology, biochemistry, lipid disorders, physics, pharmacology, epidemiology, pathology and scientific method as they apply to the practice of pediatric cardiology. In addition, knowledge of the etiology, pathophysiology, clinical manifestations, diagnosis, clinical course, treatment and prevention of all diseases affecting the heart and circulation of the fetus, infant, child, adolescent and young adult is essential.
2. Clinical Skills
   1. the ability to obtain a complete and relevant history and physical examination, including collateral history, for a young patient with suspected cardiovascular problems;
   2. proficiency in the management of acute and chronic cardiovascular problems, both congenital and acquired, in children of all ages;
   3. proficiency in dealing with the psycho-social aspects of pediatric heart disease affecting the whole family including dealing with death and grieving.
3. Technical Skills

Knowledge of the indications and risks, and competence in the performance and interpretation of:

1. electrocardiograms - at rest, during exercise and ambulatory;
2. echocardiograms, including M mode, 2-dimensional, Doppler and transesophageal;
3. hemodynamic studies and angiography;
4. therapeutic interventions and other relevant technical skills (including balloon atrial septostomy, cardioversion, temporary pacemaker insertion and pericardiocentesis);
5. insertion of central venous and arterial lines;
6. cardiopulmonary resuscitation and advanced pediatric cardiac life support.
3. Interpretive Skills

Competence in the interpretation of historical and physical findings, hemodynamic data, electrocardiograms, echocardiograms, chest radiograms, cardiac angiograms, and cardiac electrophysiological studies and permanent pacemaker surveillance.

5. Judgmental Skills

The ability to select the investigative and therapeutic management appropriate to the clinical situation, and the ability to recognize one's personal, professional, and practical limitations.

6. Scientific Skills

An understanding of the scientific method, the ability to interpret the cardiologic literature, and to formulate, execute and present a research project.

7. Teaching Skills

The opportunity to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

8. Quality Assurance/Improvement

The opportunity to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs in their hospital departments.

9. Biomedical Ethics

An understanding of ethical and medical legal requirements and responsibility pertaining to the practice of pediatric cardiology.

10. Communications Skills

The ability to effectively relate to patients, their families, and other members of the health care team.

11. Attitudes

An understanding of the obligation of lifelong self-education.

12. Research Opportunities for Residents

The program must provide the opportunity for residents to learn biostatistics and the critical appraisal of research methodology and medical literature. Each resident should be encouraged to carry out an appropriately sized research project during their residency program. Protected time needs to be developed to carry out the project and faculty should provide appropriate supervision. Faculty support for hypothesis generation, study design and data analysis should be available.

13. Faculty Research

There must be sufficient faculty research ongoing to develop an atmosphere of thoughtful inquiry sufficient to stimulate residents to acquire new knowledge. Residents need to be stimulated to continue the learning process throughout their academic careers.

14. Outside Conferences

The program should provide opportunities for residents to attend conferences outside their own university.

SPECIALTY REQUIREMENTS:

1. Certification in Pediatrics.
2. Approved residency in Pediatric Cardiology.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.