Assessing Our Trainees in the CICU
In the United States, the delivery of critical care to cardiac patients is quite heterogeneous and the units in which these patients receive their care can vary from dedicated cardiac intensive care units (CICUs) to mixed pediatric intensive care units (PICUs) to specialized neonatal intensive care units (NICUs), and no two units are exactly the same. Similarly, the providers leading the care teams in each of these units are also quite variable in training taxonomy, ranging from surgeons and anesthesiologists with specialized training, cardiology-, critical care-, and neonatology-trained intensivists with additional training, intensivists with no additional training but extensive experience, to dual-boarded cardiac intensivists. The training of these providers is not standardized and until recently, there were not even common guidelines or expectations for what one was expected to do/know coming out of training.
Earlier this year, Dr. Sarah Tabbutt and a large team of experts from PCICS published a set of standardized consensus guidelines for training programs including rotation requirements for the different pathways, institutional requirements for training programs, and an extensive list of learning objectives (https://journals.lww.com/pccmjournal/Abstract/2022/01000/Standardized_Training_for_Physicians_Practicing.8.aspx). These objectives are the foundation of the knowledge-base that pediatric cardiac intensivists should be expected to acquire during their training in order to care for critically ill children with heart disease, regardless of which path they take. In the same issue of Pediatric Critical Care Medicine, my collaborators and I published a set of nine entrustable professional activities (EPAs) for pediatric cardiac intensivists, which were generated through mixed methods with a broad and diverse group of respondents. (https://journals.lww.com/pccmjournal/Abstract/2022/01000/Establishing_Entrustable_Professional_Activities.7.aspx). These EPAs were created with input from stakeholders in all training pathways with the intent that they could be implemented into any training program where a future cardiac intensivist is trained.
EPAs are the current wave of competency-based assessment in medical education, which are meant to be easier to implement in training programs and translate to clinical practice. An EPA is an activity that a trainee would be expected to perform at various levels of mastery/independence as they enter clinical practice. For example, one of the CICU EPAs is: “Management of patients with decompensated heart failure, including management of those requiring mechanical circulatory support”, which is an activity that integrates multiple learning objectives and competencies including medical heart failure therapy, referral for advanced cardiac therapies, and management of multiple organ systems like anticoagulation, ventilation, and extracorporeal support. A faculty member assessing a trainee already subconsciously decides on a frequent basis how much they entrust that trainee to perform this activity. For instance, one trainee might be entrusted to initiate and escalate medical heart failure therapy with minimal oversight, but requires very close supervision and support to manage a patient on extracorporeal life support (ECMO), while another trainee might be entrusted to manage ECMO support with less intensive hands-on oversight. Each faculty should be able to translate this to a level of entrustment for assessment of this EPA. Each trainee is expected to attain entrustment over the course of their development, but not necessarily mastery of every EPA during their training. The further development of mastery naturally should occur during the early career with appropriate mentorship.
We are currently in the process of mapping competencies and learning objectives to each EPA and developing anchored levels of entrustment, so that these can be used in a common validated assessment tool for all trainees in our field. We hope to find ways to integrate these tools into our various training programs and I believe that this is the next step of evolution of our field into one that has more consistency and standardization in training. I also think these EPAs could apply to training and assessment in other countries and care models, though the training pathways may be quite variable. All of this, however, will be foundational to establishing pediatric cardiac critical care as a distinct subspecialty with recognition by accrediting bodies and policymakers.
David K. Werho, MD
Assistant Clinical Professor, Cardiac Intensivist
Associate Fellowship Program Director, Pediatric Cardiology
UC San Diego – Rady Children’s Hospital