Congenital Cardiac Surgery Curriculum
2.1 Purpose of the curriculum and scope of practice
The purpose of the curriculum for Congenital Cardiac Surgery is to produce, at certification, competent doctors, able to deliver excellent outcomes for patients as consultant congenital cardiac surgeons in the UK. The curriculum will provide consultant surgeons with the generic professional and specialty-specific knowledge needed to manage patients presenting with the full range of acute and elective congenital cardiac surgical conditions.
Congenital Cardiac Surgery is a specialised area of Cardiothoracic Surgery separate to surgery for acquired cardiac or thoracic pathologies. Following the Bristol enquiry1 and the Kennedy Report2 there was a clear recommendation for specialisation of children’s heart surgery. The subsequent Paediatric Congenital Cardiac Service Review (PCCS review)3 produced specific recommendations for the provision of Congenital Cardiac Surgery which can only be met through specific training and regulation of the surgeons involved. It was stated that congenital cardiac surgeons need to be ‘trained in paediatric (cardiac) surgery’. In 2013 in recognition of the need to train and produce dedicated congenital cardiac surgeons the GMC approved sub-speciality recognition of Congenital Cardiac Surgery.
Currently there are approximately 3000 open heart procedures on children per year in UK. These are undertaken in eleven designated specialised congenital cardiac surgical centres. Due to advances made in paediatric cardiac surgical and medical care, over 80% of patients born with congenital heart disease (CHD) now survive to adulthood. It is predicted that by 2020 the majority of patients with CHD will be over eighteen years of age. There is evidence that surgical outcomes for adults with CHD are better when they are operated on by paediatric trained heart surgeons than by non-specialised heart surgeons.
With the increase in the number of adults with CHD it is likely that patients with CHD will present with cardiovascular pathology separate to their congenital pathology such as ischaemic heart disease or thoracic pathology. There will also be times when patients with CHD present as an unplanned or emergency admission to a non CHD cardiothoracic centre requiring immediate intervention before transfer. A core knowledge of CHD is, therefore, fundamental for the cardiac or thoracic consultant dealing with acquired intrathoracic pathologies.
The curriculum will cover the principles and exposure to the operative management of all congenital cardiac pathologies. Practical experience in the operative management of basic and intermediate conditions is included in the curriculum. It is recognised that for the complex congenital operations first surgeon experience will be gained as a consultant whilst being appropriately mentored. Senior trainees will be entrusted to undertake the role of the Congenital Cardiac Surgery Specialty Registrar (StR) during training and will be qualified at certification to apply for consultant posts in Congenital Cardiac Surgery in the UK or Republic of Ireland.
The curriculum in Congenital Cardiac Surgery includes all aspects of neonatal, infant and paediatric cardiac surgery as well as surgery for adult congenital heart disease. The syllabus covers all emergency and elective conditions as well as transplantation, mechanical circulatory support and hybrid technology. In addition, the syllabus covers an understanding of specific medical, physiological, technical and legal aspects of working with children.
Patient safety and competent practice are both essential and the curriculum has been designed so that the learning experience itself should not affect patient safety. Patient safety is the first priority of training demonstrated through safety-critical content, expected levels of performance, critical progression points, required breadth of experience and levels of trainer supervision needed for safe and professional practice. Upon satisfactory completion of training programmes, we expect trainees to be able to work safely and competently in the defined area of practice and to be able to manage or mitigate relevant risks effectively. A feature of the curriculum is that it promotes and encourages excellence through the setting of high-level outcomes, supervision levels for excellence, and tailored assessment and feedback, allowing trainees to progress at their own rate.
This purpose statement has been endorsed by the GMC’s Curriculum Oversight Group and confirmed as meeting the needs of the health services of the countries of the UK.
2.2 Rationale and development of a new curriculum
The Shape of Training (SoT) review
4 and Excellence by design: standards for postgraduate curricula5 provided opportunities to reform postgraduate training. The Congenital Cardiac Surgery sub-specialty will produce a workforce fit for the needs of patients, producing doctors who are more patient-focused, more general and who have more flexibility in their career structure. The GMC’s introduction of updated standards for curricula and assessment processes laid out in Excellence by Design requires all medical curricula to be based on high-level outcomes. The high-level outcomes in this curriculum are called Capabilities in Practice (CiPs) and integrate parts of the syllabus to describe the professional tasks within the scope of specialty practice. At the centre of each of these groups of tasks are Generic Generic Professional Capabilities6 (GPCs), interdependent essential capabilities that underpin professional medical practice and are common to all who practise medicine. GPCs are in keeping with Good Medical Practice (GMP)7. Equipping all trainees with these transferable capabilities should result in a more flexible, adaptable workforce.
The shared CiPs support flexibility for trainees to move between the specialties in line with the recommendations set out in the GMC’s report to the four UK governments3. The GPCs are common to all medical specialties, facilitating transferability of learning outcomes across other related specialties and disciplines. This flexible approach with acquisition of transferable capabilities will allow training in specialty to adapt to current and future patient and workforce needs as well as to changes in surgery with the advent of new treatments and technologies.
The curriculum has been developed in consultation with stakeholders, including trainees, trainers, employers, lay representatives and other groups, ensuring the development of a curriculum that is fair, flexible, non-discriminatory, fit for purpose today with the capacity to evolve in future iterations in response to changing needs of patients.
2.3. Progression through training
Congenital Cardiac Surgery is a sub-specialty of Cardiothoracic Surgery occurring in phase 3 of the Cardiothoracic Surgery parent curriculum as outlined below. Trainees pursuing the Congenital Cardiac Surgery sub-specialty will be selected through a national selection process following success in the Intercollegiate Specialty Board (ISB) examination in Cardiothoracic Surgery (with a declared interest of cardiac surgery).
Although sub-specialty training will be outcome-based rather than time-based, applicants to sub-specialty training will undertake an indicative two years of training with a critical progression point at the end of sub-specialty training, satisfaction of which would lead to an ARCP outcome 6 and the ability to apply to be entered onto the specialist register as a Cardiothoracic Surgeon with a sub-specialty of Congenital Cardiac Surgery.
There will be options for those trainees who demonstrate exceptionally rapid development and acquisition of capabilities to complete training more rapidly. There may also be a small number of trainees who develop more slowly and will require an extension of training in line with the Gold Guide8: A Reference Guide for Postgraduate Foundation and Specialty Training in the UK. Trainees who choose less than full time training (LTFT) will have the indicative training time extended pro-rata in accordance with the Gold Guide. LTFT trainees will perform both elective and out of hours duties pro-rata throughout the time of LTFT.
The two-year posts will be in centres approved for training in CHD by the Cardiothoracic Surgery Specialty Advisory Committee (SAC) and will usually compromise one year in each of two collaborative training units.
Trainees who have successfully completed the two-year national training programme in the sub-specialty will be eligible for recommendation to enter the specialist register with sub-speciality accreditation in Congenital Cardiac Surgery. Trainees who do not meet the requirements of phase 3 may require an extension of training time in accordance with the Gold Guide.
The training pathway into Congenital Cardiac Surgery from the parent curriculum of Cardiothoracic Surgery is shown in Figure 1.
Figure 1: Training pathway for Cardiothoracic Surgery and the sub-specialty of Congenital Cardiac Surgery
Public inquiry into children’s heart surgery
The Report of the Independent Review of Children’s Cardiac Services in Bristol
Shape of training: Securing the future of excellent patient care
Excellence by design: standards for postgraduate curricula
Generic professional capabilities framework
Good Medical Practice
Gold Guide 8th edition