Paediatricians’ validation of learning objectives in paediatric cardiology

Abstract

BACKGROUND

The current objectives for teaching paediatric cardiology to paediatric residents have not been validated and may not be relevant to current paediatric practice.

OBJECTIVES

To validate the cardiology component of the Royal College of Physician and Surgeons of Canada’s objectives for training paediatricians.

METHODS

A questionnaire was sent to practising paediatricians in Atlantic Canada. The questions were based on the Royal College of Physician and Surgeons of Canada’s training objectives. The frequency of problems seen, confidence in assessment and management of problems, and reasons for referral were identified. Clinical vignettes were followed by short questions. The outpatient referrals were reviewed to validate the questionnaire responses.

RESULTS

One hundred fifty-one questionnaires were mailed and the response rate was 60%. Murmurs were the most common problem encountered (92%). Syncope (9%), Kawasaki disease (8%) and chest pain (6%) were less frequently encountered. Paediatricians were confident in assessing and managing problems despite the low frequency of encounters. Less confidence was expressed regarding physical examination skills and interpretation of electrocardiograms. Uncertainty of the diagnosis was the most common reason for patient referral, with parental anxiety and medicolegal concerns accounting for 24% and 7% of referrals, respectively. Syncope with exercise was relatively poorly recognized as a worrisome symptom.

CONCLUSIONS

Most cardiology objectives for general paediatric training remain relevant and appropriate to clinical practice. Physical examination skills, electrocardiogram interpretation and the assessment of syncope need to be emphasized.

If the primary outcome of paediatric training programs is to prepare trainees for independent practice, the goals and objectives of these programs should be defined largely by what is seen in clinical practice (1). In Canada, the learning objectives for certified specialty training are established by the Royal College of Physicians and Surgeons of Canada (RCPSC) (2). In paediatrics, the objectives include knowledge and expertise in cardiology. While the objectives are intuitively appropriate and based on expert opinion, their relation to clinical practice has yet to be validated. Moreover, despite the expected level of general paediatric expertise, paediatric cardiologists remain the third most common group of medical subspecialists to which children are referred (3). We sought to identify the most common cardiological problems encountered by paediatricians in Atlantic Canada and to determine which problems required referral and why referrals were made. We believed that such information would provide a framework for teaching paediatric cardiology to paediatric residents in the future.

METHODS

Study subjects

The Izaak Walton Killam (IWK) Children’s Heart Centre in Halifax, Nova Scotia, is the only paediatric cardiac surgical centre in Atlantic Canada and the primary paediatric cardiac referral centre in the Maritimes. It serves a population of approximately 1.7 million people. All paediatric cardiologists in the Maritimes are based there. The IWK Health Centre is affiliated with Dalhousie University in Halifax, Nova Scotia, which offers the only school of medicine and paediatric training program in the Maritimes.

In January 2002, all paediatricians working in Atlantic Canada were mailed a questionnaire. The paediatricians were identified through their respective provincial licensing bodies. Paediatric cardiologists were excluded.

The research protocol was approved by the IWK Research Ethics Board.

Questionnaire

The authors created a questionnaire that included demographic information, past paediatric and cardiology training experience, and current practice details. The questionnaire was largely based on the list of paediatric cardiology problems in the RCPSC general paediatric training document (2). Using this list, paediatricians were asked to rank the problems most frequently seen and referred, and to indicate their confidence in assessing and diagnosing these problems. The reasons for referral and opinions on priorities for teaching were identified. Finally, four clinical scenarios were presented, followed by questions about diagnosis and management. The scenarios are provided in appendix A. All questionnaires were coded and returned anonymously, and a second mailing was sent to non-responders.

Actual referrals

Information on new consultations to the IWK Children’s Heart Centre was collected from July 2001 to February 2002. This included demographic and clinical data regarding the reasons for referral, investigations performed and final diagnosis. The data collection was undertaken to correlate paediatricians’ perceived reasons for referral with actual referrals made to cardiologists.

Statistical analysis

Data were entered into Microsoft Excel (Microsoft Corporation, USA) and analyzed using the SPSS 10.1 for Windows statistical package (SPSS Inc, USA). Descriptive variables are given as frequencies with relative percentages. Predictors of a ‘correct’ diagnosis and referral decision for each of the scenario questions were sought using logistic regression. Statistical significance was defined as P<0.05.

RESULTS

Response rate

In total, 92 of the 151 questionnaires were returned. After adjusting for three responses stating only that the paediatrician had moved, the response rate was 60%.

Demographics

The demographic profile of the respondents is summarized in Table 1. The majority of respondents were general paediatricians working full time in large centres. Almost one-half of respondents completed their general paediatric training in Atlantic Canada. A large proportion reported that they were involved in teaching residents (75%) and medical students (88%).

TABLE 1.

Respondent demographics

	n	%
Sex
Male	43	49
Female	44	51
Training program
Atlantic Canada	43	49
Ontario	13	15
Western Canada	13	15
Quebec	7	8
United States/United Kingdom	10	11
Type of practice
General paediatrics	56	64
Subspecialty	31	36
Activity level
Full-time	80	92
Part-time	7	8
Population of practice location
10,000 to 49,999	15	17
50,000 to 99,999	12	14
≥ 100,000	59	69
Office setting
Private office	40	45
University hospital	48	54
Non-university hospital	23	26

Cardiology training

The amount of cardiology training during paediatric residency varied from three to four weeks (36%), up to eight weeks (30%). Only 5% had no dedicated exposure. Overall, 90% of the respondents felt that they had adequate training to manage the type of paediatric cardiology problems that they encountered.

Prevalence of cardiac problems and frequency of problems seen

Eighty-six per cent of respondents saw fewer than 10 patients with cardiac problems each month and 47% saw fewer than five. The cardiology problems most commonly seen in practice as reported by paediatricians are shown in Figure 1. Murmurs accounted for 92% of the most frequent problems encountered. The top three non-murmur problems were syncope (9%), Kawasaki disease (8%) and chest pain (6%).

Figure 1.

Percentage of paediatricians who ranked each cardiology problem as the one most commonly seen in their practice

Confidence

Overall, paediatricians were confident in assessing and managing most of the cardiology problems seen (Table 2). Even problems that were infrequently seen were assessed confidently; however, confidence levels decreased with infrequent exposure.

TABLE 2.

Percentage of paediatricians reporting high confidence in the assessment and management of problems listed

Percentage of paediatricians	Problems
>80	Kawasaki disease, syncope, chest pain, congestive heart failure, palpitations
>60	Acyanotic and cyanotic congenital heart disease, rheumatic heart disease
<50	Pericarditis, endocarditis, myocarditis, cor pulmonale, cardiomyopathy

The confidence levels with respect to auscultation skills, are shown in Table 3. Confidence appeared to improve with increasing patient age because neonatal, infant and adolescent systolic murmurs were distinguished confidently by 80%, 88% and 89% of the respondents, respectively. Still, 26% of the respondents stated that they had difficulty differentiating between functional and organic murmurs.

TABLE 3.

Percentage of paediatricians reporting confidence in detecting individual heart sounds

Heart sound	Percentage of paediatricians
S1	99
S2	78
S3	69
S4	58
Clicks	57
Systolic murmurs	97
Diastolic murmurs	44
Continuous murmurs	95

Only 49% of the respondents were confident interpreting electrocardiograms (ECGs), but 93% were confident assessing chest radiographs.

Self-reported referrals

Paediatricians reported suspected organic murmurs (45%) and new murmurs (29%) as the most frequently referred problems (Figure 2). Syncope (10%), Kawasaki disease (7%) and palpitations (6%) followed, and all other problems each received less than 5% of the rankings.

Figure 2.

Percentage of paediatricians who ranked each cardiology problem as the most common one referred to a paediatric cardiologist. CHF Congestive heart failure; CXR Chest x-ray; ECG Electrocardiogram

Reasons for referral

Being unsure of the diagnosis was the most common reason the paediatrician referred to a cardiologist (74%). Referral to arrange an echocardiogram (55%), to workup for a possible syndrome (48%), to verify current management (47%) and an inability to offer treatment (43%) and monitoring (23%) followed. Parental anxiety and parental request were identified as reasons for referral by 24% and 19% of respondents, respectively. Only 7% of respondents referred for medicolegal concerns.

Actual referrals

Seventy-six per cent of survey respondents referred to the IWK Children’s Heart Centre, with the remainder referring to the Janeway Child Health Centre in St John’s, Newfoundland. During the study, 232 outpatient cardiology referrals were received at the IWK Health Centre. General paediatricians accounted for only 38% of these referrals. Of the paediatrician referrals, 28% of the patients were younger than one year of age and 3% were younger than one month. Referral for the assessment of a murmur accounted for 52% of the consultations. Those with a syndrome requiring cardiac assessment made up 18.5% of referrals, followed by known congenital heart disease for follow-up (10%), palpitations (6.5%), syncope (5.4%) and abnormal investigation result for review (3.3%). Referrals for the evaluation of chest pain and hypertension accounted for the remainder. Final diagnoses for patients seen by a cardiologist are shown by category in Figure 3.

Figure 3.

The final diagnosis following referral to the paediatric cardiologist. Innocent – Innocent murmurs and patients with a final diagnosis of ‘normal heart’; NYD – Not yet diagnosed; Other – Heart disease not classified under any other heading; Structural – All forms of structural heart disease; SVT – Supraventricular tachycardia

Scenarios

The first scenario of a healthy teenager with a fixed second heart sound and a systolic ejection murmur was correctly diagnosed as an atrial septal defect by 69%, and 91% said they would refer this patient. General paediatricians diagnosed the atrial septal defect more frequently than subspecialist paediatricians. In the second scenario, a teenager who was syncopal during exercise was correctly suspected as having an arrhythmia by 71% of respondents, and 85% said they would refer the patient. In addition, 77% recognized the importance of the family history in this situation. In the third scenario, a neonate with a coarse systolic murmur at the left upper sternal border was presented. The questions about this scenario were poorly answered. Eighty-six per cent of respondents did not suspect a semilunar valve obstruction, but rather, diagnosed a patent ductus arteriosus. Nonetheless, 57% of respondents said they would refer the patient and the rest stated that they would reassess the patient within 24 h. The last scenario was that of a child with normal heart sounds and a vibratory systolic murmur. All but one respondent identified this as an innocent murmur. However, 21% of respondents said that they would still investigate further with an ECG and chest radiograph.

Predictors of response

Demographic variables (sex and age group), practice variables (activity level and type, location and setting of practice), training variables (the year the training was completed, amount of paediatric cardiology training and location of general paediatric training) and individual factors, including self-reported confidence in each of the areas assessed by the scenarios, were assessed for their usefulness as predictors of scenario answers and referral decisions using logistic regression. None of the variables were statistically significant predictors of respondents’ answers to the scenario questions.

Priorities for teaching

The objectives published by the RCPSC were identified as priorities for teaching by the paediatricians. Physical examination skills, in particular, murmur assessment, received unanimous support as a priority. The remainder of the problems, most of them infrequently seen in clinical practice, were also seen as high priority. The lowest priority was given to cor pulmonale with 43% support. To address the needs for continuing medical education, 50% preferred didactic sessions by paediatric cardiologists, 49% liked case presentations and 45% said that they would use an educational CD-ROM emphasizing auscultation skills.

DISCUSSION

We have shown that the majority of cardiology objectives published by the RCPSC for general paediatric training relate to problems that are infrequently seen in clinical practice. However, Atlantic Canadian paediatricians remain largely confident in the assessment of these problems and believe that they still hold a high priority for teaching future paediatricians.

Our study identified murmurs as the most common problem encountered by our study population. Further, the presence of a murmur is the most common reason for referral to a paediatric cardiologist. Only 60% of our referrals were for murmurs, which is in contrast to other studies reporting up to 84% to 91% of referrals (4,5). We speculate that Atlantic Canadian paediatricians are more confident and potentially more skilled in assessing systolic murmurs than those in the other studies. Self-reported confidence levels of greater than 80% in our study (which is also higher than previously published [4]) support this theory.

The reason why murmurs remain the most common reason for referral despite relative confidence in their assessment is more difficult to determine. A physician needs ‘data collection’ skills to gather the physical examination findings and ‘interpretation’ skills to generate a differential and final diagnosis. Paediatricians in our study appeared to have some difficulties with ‘data collection’. For example, many reported difficulty in splitting the second heart sound and differentiating innocent from organic murmurs. By contrast, in the scenarios where the physical examination findings were given, questions requiring knowledge of the causes of abnormal heart sounds (eg, a fixed, split S2) were answered well.

It is known that murmurs can be accurately assessed if the skills required are mastered (6). Paediatric cardiologists report a sensitivity of 96% and a specificity of 95% in differentiating innocent from pathologic murmurs compared with echocardiogram evaluations (7). Other investigators indicated a significant improvement in auscultation skills in paediatric residents who used a self-learning CD-ROM over a one-year period compared with those who did not (8). However, the time frame and amount of exposure for individuals to acquire such skills is variable (9,10), and learners are sometimes non-compliant with self-employed methods of learning such as CD-ROM-based programs (11). The availability of patients and the faculty for teaching is also becoming increasingly difficult and limited (12). The challenge for paediatric residency programs will be to find ways to teach auscultation skills in a more productive manner. This might include the use of CD-ROMs, real-time recordings and slow playback devices (10,11), and patient simulators; increasing clinical teaching rounds using model patients; or hands-on continuing medical education days.

Other areas for further training highlighted by our study include the assessment of patients with syncope and the interpretation of diagnostic tests. Among the referred patients, syncope accounted for nearly 6% of referrals and was the fourth most common reason for referral. Responses to the scenario questions about the patient with syncope during exercise were answered poorly, with only 71% recognizing the potential arrhythmogenic cause and referring the patient.

The interpretation of commonly used investigations for cardiac disease also appears to be poorly taught. Only 49% of paediatricians expressed confidence in ECG interpretation. The chest radiograph and ECG are frequently the only initial investigations available to a community paediatri-cian assessing a patient with a potential cardiac problem (13). Other authors question the usefulness of continuing to teach ECG interpretation (14).

While there is almost always a clinical reason that drives a referral, paediatricians told us that parental anxiety (24%) and parental request (19%) were sometimes reasons for referral. This differs from a study in the American medical system in which parental anxiety and parental request were referral factors according to 14% and 6% of the responders, respectively (4). This may relate to the costs of such referrals in the United States, compared with the universally available health care system in Canada. In addition, the higher litigation rates in the United States may explain the fact that 13% of the respondents, compared with 7% of ours, listed medicolegal issues as a reason for referral.

The limitations of the present study include the suboptimal response rate, which (though comparable to other studies of this nature [1]) potentially restricts its generalizability. The questionnaire design also created some unforeseen problems with the analysis in that often not all questions were answered, so the denominator for each question varied. Also, by providing lists of cardiology problems for the respondents to rank, the survey may have proved to be too long, potentially leading respondents to answer by marking all objectives as high priority. This may have limited our ability to delineate specific teaching priorities for the future. Our assessment of actual referrals involved only those at the IWK Health Centre. Patients referred to the Janeway Child Health Centre were not assessed. Due to the similarity of the populations in the Maritimes and Newfoundland, we do not anticipate that inclusion of this group would have had a significant impact on our results.

CONCLUSIONS

Paediatricians feel that current cardiology teaching objectives for general paediatric training, as defined by the RCPSC, remain a priority despite the relatively infrequent exposures to most of the problems in clinical practice. Heart murmurs remain the most common problem encountered and referred by paediatricians in Atlantic Canada. This is followed by syncope, Kawasaki disease, and chest pain and palpitations. We identified physical examination skills, ECG interpretation and the assessment of syncope as topics that should be emphasised as future priorities for teaching paediatric residents and paediatricians.

APPENDIX A Scenarios presented in the questionnaire