Paediatric cardiology
Shakeel Qureshi, Susan Hobbins, and Nitha Naqvi explain why they think that paediatric cardiology is an exciting and rewarding job which could appeal to you
The stereotypical image of a paediatric cardiologist--an aggressive and boisterous male, found in the catheter laboratory at all hours, and lacking in communication skills--is outdated. Some old school paediatric cardiologists may still exist, but the new breed of trainees represents a more modern range of junior doctors, and more women are appointed as consultants than in the past. The specialty has begun to branch into specific areas of expertise: some doctors are mainly interventionalists working in the catheter laboratory, but others specialise in imaging (echocardiography, including fetal and magnetic resonance imaging). So if you are one of those doctors who enjoy using their surgical skills but who also enjoy practising medicine, this is an ideal job. For those who do not want to spend a lot of time in the catheter laboratory, there are lots of other interesting and challenging areas.
Despite some adverse publicity over the past few years, the specialty remains one of the most rewarding. Because of the structurally abnormal nature of the heart defects, they are amenable to logical detection and management. Making a diagnosis in a sick blue newborn baby and quickly carrying out treatment, leading to a healthy pink robust infant in a short time, is rewarding. Paediatric cardiology allows follow up of progress from the fetus to the adult. Until about 20 years ago, treatment of complex heart defects had a mortality of more than 20%, but with major advances mortality has now fallen to less than 5%. Box 1 gives the advantages and disadvantages of paediatric cardiology.
Box 1: Advantages and disadvantages
Advantages
- High tech
- Considerable practical element
- Exciting
- Mentally challenging with physics and physiology elements
- Many subspecialty interests including arrhythmias, magnetic resonance imaging, fetal, interventional
- Provides continuity of care
- Well funded
- Non-resident on-call
Disadvantages
- Under public glare, with press interest in mistakes
- Parents more likely to go to the courts than with other specialties
- Some children die during follow up--inevitably distressing
- Old fashioned working environment with high expectations on juniors regarding commitment, including long hours
- Specialty attracts competitive individuals
- Intense competition for national training numbers, with bottleneck at this level
Specialist in paediatric cardiology
Entry into a training programme
The career path to a consultant post entails five years of higher specialist training in paediatric cardiology at one of 15 tertiary paediatric cardiology units in the United Kingdom (box 2). For entry into the programme you need to pass the exams of one of the royal colleges (MRCP or MRCPCH) or equivalent and two years of general professional training at senior house officer or registrar level, or both, of which at least six months must be in general paediatrics and six months in neonatal intensive care (preferably in a regional referral unit). If your general training has not included general paediatrics and neonatology, you will have to arrange it as out of programme training soon after entry into specialist registrar training in paediatric cardiology. So even if you are a trainee from adult medicine, flexibility allows you to enter into the programme, but you will need to obtain experience in paediatrics. As a trainee in paediatric cardiology, you will need to show aptitude in practical skills including echocardiography and cardiac catheterisation in neonates, infants, and children. A previous senior house officer or registrar post giving some experience in echocardiography is helpful but not essential.
During training you learn in detail about all types of congenital heart defects, their pathophysiology, non-invasive and invasive investigations, surgical and non-surgical management, prenatal detection, and following through to adult life. You learn the basic skills in cardiac morphology and imaging (echocardiography) in the first year. The wide variety of non-invasive investigation techniques includes echocardiography, trans-oesophageal echocardiography, magnetic resonance imaging, and telemetric monitoring. Training then moves on to the more difficult skills such as cardiac catheterisation, interventions, fetal echocardiography, and electrophysiology. The invasive non-surgical treatments include interventional techniques to close holes or open valves and
vessels. Other procedures entail electrophysiological investigations and treatment. Catheter closure of defects, such as atrial septal defects and patent arterial ducts, with a device is now one of the commoner interventional procedures performed in the catheter laboratory.
The current curriculum in paediatric cardiology leads to a certificate for the completion of specialist training (CCST) based on training for five years, but the newly developed competence based curriculum, which will become effective in 2003, although currently still five years may shorten the duration of training in the future. Such competency based assessment should also benefit flexible trainees because the CCST would be awarded when the trainee is deemed ready and competent to be a consultant.
You can obtain a comprehensive curriculum from the JCHMT office (see further information).
How do I get a national training number post?
Prospects for consultant jobs look excellent for the next 10 years. In the earlier stages of training you may have difficulties in securing a national training number (NTN) post, but with sound advice at an early stage, the process becomes easier. Currently, there are 28 specialist registrar posts in paediatric cardiology in the UK, but further expansion is imminent. Usually there are about 20 applicants for each post. If you are able to obtain a locum appointment for training (LAT) or locum appointment for service (LAS) or a research fellow post in paediatric cardiology, you may have an advantage over those candidates without any previous paediatric cardiology experience. Up to 12 months of LAT experience can be considered towards a subsequent type I training programme. There is no advantage in accepting LAT or LAS posts longer than 12 months' duration. It is important to remember that LAS posts cannot be counted towards the subsequent higher training. Once you are on the ladder, your training can be geared towards your personal requirements. There is no dual accreditation. A research year is advantageous and encouraged but is not mandatory.
A typical week
A typical week in paediatric cardiology entails a regular daily multidisciplinary echocardiography conference to review the previous day's admissions, a ward round, a clinic (which may include up to 20 patients needing echocardiographic investigation and management discussions), meetings with parents, and administrative work. Then there is cardiac catheterisation, a weekly surgical conference (where management of complex cases is discussed), teaching of junior doctors, audit and research, and attendance at outreach clinics in conjunction with a paediatrician with special expertise in paediatric cardiology.
Paediatrician with special expertise in paediatric cardiology
Some trainees may wish to retain a general paediatric career but develop a special interest in paediatric cardiology. Recent exciting developments may enable such a career path. A one year curriculum for a paediatrician with special expertise in paediatric cardiology has been developed. This will allow a general paediatric trainee with an NTN in paediatrics to enter a one year training programme in years 4 or 5. Similar training is also possible once the CCST is achieved. This one year module is undertaken at a tertiary paediatric cardiology unit and has a programme similar to the one for paediatric cardiology trainees, modified to emphasise the particular needs of patients in district general hospitals. Such children need local non-invasive investigations including echocardiography, exercise testing, and telemetry, and the support of a paediatrician with knowledge of congenital heart disease. These paediatricians work closely with a tertiary centre, having regular weekly clinical sessions at the tertiary centre, and hold local joint cardiac clinics providing continuity of care for children with congenital heart defects.
Currently there are no specific NTNs for training as a paediatrician with special expertise in paediatric cardiology. However, it is expected that NTNs will be allocated for such a training programme in the future.
A typical week
A typical week includes daily general paediatric and neonatal ward rounds, general paediatric clinics (including evaluation of patients with murmurs), echocardiography clinics, and a clinical session at the tertiary centre with a paediatric cardiologist. You would also provide expertise and advice on paediatric cardiac problems to other paediatricians at the district general hospital, participate in audit and teaching, and do a regular all day joint cardiac clinic with a visiting paediatric cardiologist (in which up to 30 children with considerable heart problems are seen). Children with innocent murmurs will have already been seen by general paediatricians in other clinics. This is in addition to all the normal duties of a general paediatrician.
A paediatric cardiology trainee's perspective
"I chose this specialty because it combines looking after very sick babies and children in the intensive care environment and also allows continuity of care with interaction with awake children on the ward and in the clinic. This retains the rewarding aspect of the practice of paediatrics in following children from the fetus to adult life.
Paediatric cardiology is a high tech specialty but still relies on clinical skills learned in medical school, including using the old fashioned stethoscope. Starting paediatric cardiology is similar to starting neonatology, where every day you learn an enormous amount in an exponential manner. I use the knowledge and skills I learnt as a paediatrician constantly in paediatric cardiology since our patients still get all types of general paediatric problems. In addition, there is a large practical component with echocardiography and cardiac catheterisation. Following the Bristol controversy, I was worried that parents would be demanding and suspicious, but I have found the interaction with parents to be rewarding and most are grateful, even when children do not pull through. Certainly this job is hard work and very busy, but coming from a general paediatric specialist registrar background, an enormous bonus is that the on-call is non-resident."
Another new and exciting development is the creation of a specialty interest in management of adults with congenital heart disease. Such a career path is designed for trainees with a background in paediatric cardiology or adult cardiology.
After the first three years in general cardiology training, which will include one year with additional training in general internal medicine, trainees wishing to specialise in adult congenital heart disease will rotate to a tertiary referral centre for patients with congenital heart disease, including adults. The training will cover all aspects of congenital heart disease and must include a period of at least six months in the care of infants and children.
The first three years will be spent in general paediatric cardiology, followed by two years in adult congenital heart disease, including six months general (internal) medicine in a district general hospital. An additional year, out of programme, for research or additional training is desirable. At present, five NTNs have been allocated in the United Kingdom for such a career path and this number will have to increase in the future.
The good news for trainees is that following the Bristol inquiry there will inevitably be an increase in the number of consultant jobs, and career prospects are excellent for the next 10 years.
