Background

Pediatric cardiology is a highly procedural and technology driven field, with training vastly different from other pediatric sub specialties. Learners are thrust into a field with little overlap with their prior general pediatrics training.

For over 25 years, echocardiography has been the mainstay in the assessment of anatomy and physiology in congenital heart disease (CHD).¹ During core fellowship training, all pediatric cardiology fellows are expected to achieve technical competence in transthoracic echocardiography, which requires hands on skills and a solid knowledge base. In 2015, training guidelines for pediatric cardiology fellowship programs were updated and include technical skills (i.e., procedural echocardiography) and medical knowledge (i.e., interpretive echocardiography).²

Competence in both procedural and interpretive echocardiography is essential to the practice of pediatric cardiology.^2,3 Echocardiography is operator-dependent and requires a high level of competence in both technical and interpretive skills.⁴ Procedural echocardiography is the "act" of performing an echocardiogram and obtaining all relevant views. Interpretive echocardiography involves knowledge of anatomy and physiology and cognitively applying the information to formulate a diagnosis. On average, each fellow has 4-6 months of dedicated echocardiography training during a standard 3-year fellowship.^3,5 Delayed or inaccurate diagnoses can place children with CHD at risk for adverse outcomes.⁶

Traditionally, cardiology fellows obtain much of their echocardiography experience while on call on nights and weekends. However, changes in work-hour restrictions have introduced new challenges.⁷ One major challenge involves varying training experiences and exposure to the breadth of clinical pathology.^8-10 Achieving proficiency may be protracted due to certain congenital heart defects that are rarely seen in some practice settings.^11,12 Studies have shown that the variety of patients and diseases are as important as volume of procedures.^8,13 Variability in clinical pathology can compromise the quality and breadth of fellowship training and may pose a challenge in the assessment of competency in echocardiography which may thus be subjective. However, sub-specialty Boards are trending towards more objective evaluations to assess performance and mastery.^13-16 Objective metrics would enhance fellows' self-assessment of progress and fellowship program directors' ability to assess learning and curriculum efficacy. The pediatric cardiology training programs that have implemented objective echocardiography testing exhibit improved trainee performance on the American Board of Pediatrics examinations.¹⁵

Developing Procedural Skills in Echocardiography: Echo Boot Camp

Many surgical and procedurally driven fields have developed short, intensive training "boot camps" which have reported subjective improvement in trainees' comfort levels as well as objective technical improvements in their skills.¹⁷ In 2012, our institution implemented a dedicated "echo boot camp", a 3-day intensive training program in pediatric echocardiography for in-coming pediatric cardiology fellows.⁷ It focuses on procedural skills through hands-on scanning workshops with model patients. Fellows are divided into small groups where they have the opportunity to master each echo view with one-on-one instruction and immediate feedback. Ample time is provided to allow skill development in a graded fashion. The boot camp also provides introductory didactic instruction with focused lectures on the basic principles of ultrasound, segmental approach to cardiac anatomy, relevant imaging planes and "knobology."

Promoting Medical Knowledge in Interpretive Echocardiography: A Web Based Approach

A novel online introductory web based learning platform (https://pedecho.org/) was developed to improve competency in interpretive echocardiography. This website provides tutorials in pediatric echocardiography and an image library of various congenital heart defects with interactive learning modules that include relevant images, video clips, and options to receive "layered support" (i.e., labels on the images with supplementary explanations).

The trainee has the ability to navigate through the library and construct a personal learning pathway or may elect to follow a suggested curriculum where interpretative knowledge and skills are built in an iterative manner.

A pilot study is currently being conducted utilizing this comprehensive platform, combining the boot camp and online instruction. We hypothesize that this program will be an effective educational tool to improve short and medium-term retention of knowledge and skills in pediatric echocardiography.

Future Directions

As online education evolves, emphasis will be placed on building additional functionality and objective assessment, including:

1. Improving the ability of faculty to assess learners' competency by constructing examinations and reviewing performance.
2. Evaluating how the library may be used for 'just-in-time' clinical decision support for learners at the point of care.
3. Enabling faculty from other institutions to contribute images and interesting cases to be included in the library, with appropriate attribution.
4. Exploring the possibility of building a community that provides peer-to-peer interactions using threaded forums or other technologies.
5. Mobile-friendly access that allows for convenient "learning on demand".

Conclusion

Developing competency in pediatric echocardiography is a complex process. A solid foundation is essential to build core knowledge that evolves throughout fellowship, with equal emphasis on both procedural and interpretive skills. Hands-on training through an echo boot camp allows fellows to build a foundation in their procedural skills. An online learning platform develops interpretative skills, may be accessed by many learners irrespective of location, is easy to implement once developed and may be user adaptive.

References

1. Srivastava S, Printz BF, Geva T, et al. Task force 2: pediatric cardiology fellowship training in noninvasive cardiac imaging. J Am Coll Cardiol 2015;66:687-98.
2. Allen HD, Bricker JT, Freed MD, et al. ACC/AHA/AAP recommendations for training in pediatric cardiology. Pediatrics 2005;116:1574-96.
3. Graham TP, Beekman RH, American College of Cardiology Foundation, American Heart Association, American College of Physicians Task Force on Clinical Competence (ACC/AHA/AAP Writing Committee to Develop Training Recommendations for Pediatric Cardiology). ACCF/AHA/AAP recommendations for training in pediatric cardiology: training guidelines for pediatric cardiology fellowship programs. J Am Coll Cardiol 2005;46:1380-1.
4. Lai WW, Geva T, Shirali GS, et al. Guidelines and standards for performance of a pediatric echocardiograph: a report from the Task Force of the Pediatric Council of the American Society Echocardiography. J Am Soc Echocardiogr 2006;19:1413-30.
5. Graham TP, Beekman RH, Allen HD, et al. ACCF/AHA/AAP recommendations for training in pediatric cardiology: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence. Circulation 2005;112:2555-80.
6. Benavidez OJ, Gauvreau K, Jenkins KJ, Geva T. Diagnostic errors in pediatric echocardiography: development of taxonomy and identification of risk factors. Circulation 2008;117:29995-3001.
7. Maskatia SA, Altman CA, Morris SA, Cabrera AG. The echocardiography "boot camp": a novel approach in pediatric cardiovascular imaging education. J Am Soc Echocardiogr 2013;26:1187-92.
8. Eisenberg MJ, Rice S, Schiller NB. Guidelines for physician training in advanced cardiac procedures: the importance of case mix. J Am Coll Cardiol 1994;23:1723-5.
9. Stewart WJ, Aurigemma GP, Bierman FZ, et al. Guidelines for training in adult cardiovascular medicine. Core Cardiology Training Symposium (COCATS). Task Force 4: training in echocardiography. J Am Coll Cardiol 1995;25:16-9.
10. Yu E. The assessment of technical skills in a cardiology training program: is the ITER sufficient? Can J Cardiol 2000;16:457-62.
11. Wagner R, Razek V, Grafe F, et al. Effectiveness of simulator-based echocardiography training of noncardiologists in congenital heart diseases. Echocardiography 2013;30:693-8.
12. Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002;39:1890-900.
13. Quinones MA, Douglas PS, Foster E, et al. ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. J Am Coll Cardiol 2003;41:687-708.
14. Kugler JD, Beekman RH, Rosenthal GL, et al. Development of a pediatric cardiology quality improvement collaborative: from inception to implementation. From the Joint Council on Congenital Heart Disease Quality Improvement Task Force. Congenit Heart Dis 2009;4:318-28.
15. Hao M, Ippisch HM, Cook RS, et al. Implementation of an objective testing system in noninvasive cardiac imaging for evaluation of pediatric cardiology fellows. J Am Soc Echocardiogr 2007;20:1211-8.
16. Thomas JD, Zoghbi WA, Beller GA, et al. ACCF 2008 training statement on multimodality noninvasive cardiovascular imaging: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training developed in collaboration with the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society for Vascular Medicine. J Am Coll Cardiol 2009;53:125-46.
17. Cohen ER, Barsuk JH, Moazed F, et al. Making July safer: simulation-based mastery learning during intern boot camp. Acad Med 2013;88:233-9.

Keywords: Cardiology, Child, Echocardiography, Heart Defects, Congenital, Pathology, Clinical, Pediatrics

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