Rethinking Paediatric Cardiology Training in Canada

With the field of congenital and paediatric cardiology undergoing significant changes and modifications over the past half century leading to improved outcomes, the training of a paediatric cardiologist in Canada has remained relatively constant. There is a worldwide trend towards formalizing paediatric cardiology training; however, there still remains significant variability between how paediatric cardiology training is administered in terms of scope, length, and prerequisite training.¹ We feel that specific solutions tailored to factors that are pertinent to the Canadian landscape should be considered as we propose new solutions in the era of competency by design and competency-based medical education.² We feel that there is a unique window of opportunity to rethink paediatric cardiology training in Canada that may better suited to our patients, faculty, and trainees moving forward into the next decades. We hope that this editorial can ignite the dialogue on how we can better train and recruit the next generation of paediatric cardiologists.

Globally, there are many training pathways to become a paediatric cardiologist. This can take the form of a structured and licensed pathway following general paediatric training, or in some jurisdictions following adult cardiology training, to an informal “apprenticeship” depending on the resources and availability. In Canada, we adopt a structured approach to training paediatric cardiologists that includes general paediatric residency followed by 3 years of paediatric cardiology training and, for most, another 1 year of subspeciality cardiology training (ie, noninvasive imaging, cardiac catheterization, electrophysiology, and heart failure/transplantation).3, 4, 5 The Royal College of Physicians and Surgeons of Canada recently increased the mandatory duration of general paediatric training from 3 to 4 years across the country. In Ontario, the paediatric residents who will start subspeciality training in July 2025 will have had to complete 4 years of paediatrics before starting training in paediatric cardiology. The result is that the total length of postgraduate training will increase to a minimum of 7 years and in most cases 8 years. This will make our postgraduate training the longest of all paediatric subspeciality trainings.

The length is significant for multiple reasons. For one, the total duration of postgraduate training in Canada is now longer than that in some European countries such as the United Kingdom and Ireland, as well as South American countries such as Brazil¹ (see Table 1). Although the Canadian and European training pathways are comparable in some respects, 2 stark differences are apparent. First, the Canadian trainees usually start medical school at a later age, and second, they typically graduate with substantial debt due to high tuition fees. The current estimates show that around 30% of Canadian medical graduates have student debt between CAD$80,000 and $140,000 and over 10% have debts upwards of $200,000.⁶ This coupled with the reality that our speciality is less financially lucrative than our adult counterparts may significantly impact our ability to recruit in the future.⁷ Multiple studies have shown that a high debt burden has negative effects on our trainees’ mental health and their academic performance, and can influence speciality choice.8, 9, 10 If one considers debt as a substitute for socioeconomic status and that debt may be a barrier to choosing a long subspeciality training, one could see how this could worsen the diversity of the paediatric cardiology workforce moving forward.¹¹

Table 1.

Comparison of training fellowships/systems across different countries¹

Country	Training (y)	Advanced training∗	Exit/certification
Canada	3-4	Yes (1-2 y)	Board certification, FRCPC in PC
United States	3-4†	Yes (fourth year)	Board certification
United Kingdom	5	Yes (1-2 y)	CCT
Ireland	5	Mixed	CSCST
Belgium	3	Mixed	Paediatrics certification
Brazil	2-4‡	Mixed	National certification
India	3	International	DNB or DM (2 streams)
South Africa	3	International	Certificate in PC
Nigeria	Variable	International	None

CCT, Certification Completion of Training; CSCST, Certification of Satisfactory Completion of Specialist Training; DM, Doctorate of Medicine; DNB, Diplomate of the National Board; FRCPC, Fellow of the Royal College of Physicians of Canada; PC, paediatric cardiology.

^∗Advanced subspecialist training is available in the trainee’s home country or an international centre or mixed options.

^†Optional fourth year of subspecialist training.

^‡Optional fourth year of subspecialist training at home or abroad.

It is widely accepted that high stress in postgraduate medical training leads to burnout, increased health issues in trainees, and medical errors.¹² It is reasonable to assume that our speciality is perceived as high stress and that this could deter strong and motivated paediatric residents from entering our field. A study from Boston Children’s Hospital looked at common sources of stress in new trainees starting paediatric cardiology fellowship by asking all new fellows the question, “what are you afraid of in the coming year?” Over 80% of new fellows felt that “fellowship/career responsibility” was a significant fear for them.¹² This perceived fear of inadequacy is likely multifactorial. For one, it may be due to the lack of understanding basic physiology and haemodynamics in patients with congenital heart disease. On the other hand, it may be compounded by a lack of technical skills in echocardiography or catheterization that are essential to practicing and succeeding in cardiology training. We have all heard the adage that “first year cardiology is difficult,” and we wonder why the knowledge gap needs to be so high. How do we mitigate this cliff edge that our first-year trainees face?

The net effect of all these factors has led to the Canadian Resident Matching Service applications at Canada’s largest children’s hospital and largest fellowship programme to decrease from 6 applicants in 2017 to just 1 in 2022 and 2023. Figure 1 shows the factors involved in this change. As we extrapolate this into the future, with increased debt burden, many of our training positions located in expensive cities, and a field with a very long training timeline, one can make a reasonable assumption that paediatric cardiology will become less desirable.¹³ At this point, we are on par with cardiothoracic surgery/neurosurgery in terms of length of training, but those fields typically have significantly more financial remuneration for the upfront cost of training length.¹³ Our field is intrinsically fascinating, and we hope to continue to inspire the next generation to care for our patients, but the recent decrease in Canadian applicants warrants, at the very least, a discussion about whether such extensive paediatric training is required to be a clinically excellent paediatric cardiologist.

Figure 1.

Factors discussed in this work that should prompt education reform in paediatric cardiology training in Canada.

Our solution? A 5-year direct entry programme into paediatric cardiology after the completion of medical school. Early exposure to paediatric cardiology would be woven into the first couple of years of training that would be focused on acquiring the competencies of general paediatrics. This may help with alleviating the cognitive burden that is rampant, as shown in Boston Children’s Hospital paper, when our trainees start more intensive cardiology training in their third year of training.¹² Although radical in some respects, this type of training format has already been shown to be successful in a Canadian context, with paediatric neurology being a 5-year direct entry programme from medical school.¹⁴ We feel that this may also incentivize more strong candidates to join the field of paediatric cardiology and remove some barriers (training length and financial stressors) that theoretically could stop strong and socioeconomically diverse candidates from applying at present.

One clear downside to this proposal is what would happen should a trainee leave the programme before completion. In a direct entry programme, the trainee would leave with no qualifications and would have to begin again in an alternative residency programme as opposed to being able to practice as a general paediatrician as would be the case in the traditional model of training. At present, in the case of our paediatric neurology colleagues, their training does not allow for them to be a board-certified paediatrician. This begs the question, would we still have a 3-year programme that could be offered after paediatrics for those who decide to join our field later on? These are all real valid questions that would need to be addressed.

The debate on having 3 years, now 4 years, of general paediatrics knowledge before entering paediatric cardiology is nothing new. Over 10 years ago, Dr Douglas Moodie of Texas Children’s Hospital questioned the need for 3 years of paediatrics before cardiology training.¹⁵ He postulated that 2 years is likely enough, and that as a field, we could consider stratifying the streams into a paediatrician with a special interest in cardiology and others who want to become an academic paediatric cardiologist.¹⁵ Ten years ago, Dr Moodie did bring up a 3- to 5-year fellowship for those interested in practicing academic cardiology at a large tertiary care centre in the future.¹⁵ Ten years later, we think the time is now to consider this, especially in Canada.

The reason we think the time is now is that postgraduate medical education is at a significant inflection point in the era of competency-based medical education. In 2010, 4 organizations (the Association of Faculties of Medicine of Canada, the Collège des Médecins du Québec, the College of Family Physicians of Canada, and the Royal College of Physicians and Surgeons of Canada) formed a consortium and, with $1.8 million in financial support from Health Canada, undertook a thorough review of postgraduate medical education in Canada.² At that point, they came up with a set of guiding principles to improve postgraduate training to help with, among other things, the distribution of physicians and content of the curricula.² We feel that if the correct competencies from paediatrics training were integrated into paediatric cardiology training, it could effectively streamline the training of a paediatric cardiologist.

A cardinal rule in innovation is to always use first principles to understand the basics of any situation to remove unnecessary steps and create more efficient techniques in the process. In medical education, many times things are the way they are due to momentum, which is to say just because that is how we have done them in the past. We hope that the consideration of paediatric cardiology education reform would, at best, improve the quality of the trainees and future practitioners in our field and, at worst, at least create a discussion around paediatric cardiology training in Canada and future obstacles.

Although there are many considerations of course, we feel that the barriers and factors that keep strong paediatrics resident away from paediatric cardiology may not impact our field at present, but will have a lasting impact moving into the future. The concerns around training length with increased debt burden are significant, and we ask that key stakeholders in the field of paediatric cardiology in Canada be open to a discussion on reimagining what paediatric cardiology training could look like and whether there is a better way forward.

Despite many innovations in the field of paediatric cardiology and congenital heart disease, the training of paediatric cardiologists in Canada has been unchanged. With increasing barriers to join the field that include clinical stressors, high debt burden, and a prolonged training duration, there is a concern that the field may become less desirable in the future, which may affect the quantity and quality of candidates moving forward. In this editorial, we propose a reform to paediatric cardiology training in Canada, with a solution that includes a modernized 5-year direct entry programme from medical school with integrated general paediatrics and paediatric cardiology training. With recent changes in postgraduate paediatric training including competency by design as well as increasing length of paediatric training to 4 years, we feel now is a window of opportunity to discuss how we train our paediatric cardiologists of the future. With a similar structure seen in paediatric neurology, we feel that there is precedent for this type of change. We propose that key stakeholders within the paediatric cardiology field in Canada at least consider and discuss how we will address this important workforce concern.