Specialized training and certification in pediatric cardiac critical care lacks standardization and oversight, prompting calls for mandatory certification to ensure quality care for high-risk patients.
Most all tertiary children’s hospitals have at least three ICUs for the most critically ill newborns, infants, and children: the neonatal ICU (NICU), the PICU, and the cardiac ICU (CICU). For physicians undergoing specialized training for working in the NICU or PICU, strict oversight is managed by the Accreditation Council for Graduate Medical Education (ACGME), while certification and continuing medical education are overseen by the American Board of Pediatrics (ABP). However, currently, no specialized training, certification, or continuing medical education is available for those physicians choosing a career in CICU. There are currently several training pathways to prepare for a career in pediatric cardiac critical care. The three most common are: 1) a categorical fellowship in pediatric cardiology followed by a specialized fourth year in cardiac intensive care, 2) a categorical fellowship in pediatric critical care followed by a specialized fourth year in cardiac intensive care, and 3) categorical fellowships in both pediatric critical care and pediatric cardiology (allowed in 5 yr). However, there is no standardization or oversight to the cardiac critical care training and no certification or continued certification. This absence results in uncertainty when hiring faculty and lack of transparency to the public/parent on the qualifications of the physicians. Certification categorical fellowships in either pediatric cardiology or pediatric critical care is limited in the granularity of questions regarding cardiac intensive care as the certification examination is also taken by general cardiologists and general intensivists. Thus, the elephant in the room: who trains and certifies pediatric cardiac intensivists? There is extensive science behind medical training, which is leveraged by the ACGME. There is also the science behind standardized testing, which is leveraged by the ABP. Replicating these systems by another organization would be a huge undertaking and not practical if only supporting pediatric cardiac critical care. Appeals to the ABP for subspecialty certification and maintenance of certification have been denied (most recently in November 2022 (S. Woods, personal communications, 2022). As a result, standardized training and certification has fallen on the shoulders of the pediatric cardiac critical care community. Subspecialty training in pediatric cardiac critical care was first published by pediatric cardiologists (1) in 2005 with a quick rebuttal by pediatric intensivists (2). Subsequently, there have been many articles addressing the importance of subspecialty training in pediatric cardiac critical care (3–8). Due to an increasing anxiety over the lack of standardization of training and certification, at the encouragement of the APB and the Pediatric Cardiac Intensive Care Society (PCICS) a task force was established including all directors of pediatric cardiac critical care fourth year programs in addition to medical education experts to establish a training consensus. In addition to curriculum and learning objectives, training center qualifications were also established (Tabbutt et al 9). A partner article outlined the entrustable professional activities (EPAs) for pediatric cardiac critical care, which are the cornerstone of ACGME training (Werho et al 10). Unfortunately, the ABP decided against endorsement (S. Woods, personal communication, 2022), leaving the PCICS to navigate. From the ABP’s perspective, there is a significant financial and work force commitment to supporting a new subspecialty certification and maintenance of certification. With approximately 125 congenital heart centers in the United States, one might expect 600–1300 physicians caring for critical cardiac patients. However, in the absence of expectations of specialized training, it is challenging to determine the number who will participate in formal certification in cardiac critical care. One might anticipate if specialized training and certification is offered by the ACGME and ABP that might readily become the standard. There is an additional consideration of a slippery slope; if cardiac intensive care becomes a subspecialty what about cardiac catheterization or neurocritical care? A final deterrent is expense to the individual physicians certifying and maintaining board certification for potentially three boards (Pediatrics, Categorical Fellowship, and CICU subspecialty training). Threading the needle between the very detailed learning objectives in the article by Tabbutt et al (10) and the perhaps abbreviated EPAs in the article by Werho et al (10), the PCICS sponsored article by Chlebowski et al (11) provides an essential approach. All three of these articles should be considered by sites providing specialized training in pediatric cardiac critical care. While it is impossible for the PCICS to oversee training and certification at the level of the ACGME and the ABP, the energy of the community is admirable. As patients in the CICU are often the most critical in the hospital, it is confusing why the ABP and subsequently the ACGME do not provide specialized training and certification for the physicians caring for this high-risk population. Perhaps specialized training (or its equivalent) in pediatric cardiac critical care should be mandatory and reflected in the Joint Commission and U.S. News and World Report assessments.
Tabbutt et al. (Sat,) conducted a editorial in Pediatric critical heart disease. Specialized training and certification was evaluated. Specialized training and certification in pediatric cardiac critical care lacks standardization and oversight, prompting calls for mandatory certification to ensure quality care for high-risk patients.