Guest Editorial: Incremental Innovation in the Medical Education of Pediatric Cardiac Intensivists

Hector Wong, a passionate pioneer of pediatric critical care and a kind mentor to countless physicians including myself, suddenly and unexpectedly passed away at the start of this year^1,2. While much of his expansive research body focused on pediatric sepsis, a less-cited work of his is a 2015 treatise on innovation in pediatric cardiac intensive care, presented at the 10^th International PCICS Conference a few months prior to publication³. In it, he and his co-authors define innovation as “solving problems with a process that begins with creativity and ends with execution”, and subtype it into incremental, disruptive, breakthrough, and game-changing. They go on to highlight four areas of innovation deserving special attention in pediatric cardiac intensive care: genomic medicine, nanomedicine, artificial intelligence, and medical education. You read that right – education, primeval yet timeless, was uttered in the same breath as three highly technological fields that were hardly in existence a mere century ago. How is this so, and how have we fared so far?

It’s important to note that most innovation is of the incremental subtype, where there are moderate alterations to existing services or products. Yet, incremental does not mean slow, and in fact much of the growth and modernization of physician education in our relatively young field of pediatric cardiac intensive care has only taken place in the past decade, with lots more work to be done. The motivation has been multifactorial, starting with efforts to align our training and potential certification process with that of well-established categorical fellowships while also acknowledging the existence of various training pathways in pediatric cardiac intensive care^4,5. Pertinent as well has been the realization that a generational transition is upon us, where we “digital immigrants” will be training (and will eventually be supplanted by) “digital natives”, and that teaching methods must continually adapt to meet our learners’ needs³. Most recently, the COVID-19 pandemic has accelerated the need for virtual and often asynchronous learning modalities.

Excitingly, PCICS members have been at the forefront of this incremental innovation, chairing task forces on establishing requirements for pediatric cardiac critical care training in pediatric cardiology fellowship as early as 2005, with organizational endorsement from the PCICS in a subsequent iteration a decade later^6,7. Switching the focus to stand-alone pediatric cardiac intensive care training, an Education committee was established within the PCICS in 2015 and amongst its early work was the successful release of the PCICS Physician and Simulation Curriculum for Pediatric Cardiac Critical Care^4,8. Centers have used this material to create local didactic and simulation curricula for their advanced and categorical fellows, advanced practice providers, and nurses^9,10.

The PCICS Education committee also houses the Subcommittee of Pediatric Cardiac Critical Care Training Program Directors, a group that has worked tirelessly to enhance the educational experience for advanced fellows. After many years in the making, and in partnership with expert academic clinicians in the field, statements on standardizing training of advanced fellows and on establishing specific entrustable professional activities (EPAs) for said trainees were just released^11,12. As a recently minted program director, I have found these resources invaluable in optimizing the advanced fellowship training provided at my institution. The subcommittee has also unified the enrollment process for physicians seeking pediatric cardiac critical care training, including creating a common application form and timeline that was first rolled out in the 2021 application season with success¹³. We continue to gather data from applicants and program directors alike on how to further refine the process for future application cycles. Finally, a multi-institutional fellow-led virtual journal club has been borne from this subcommittee, creating a safe setting for pediatric cardiac critical care fellows to share seminal research in the field and to form crucial connections with their colleagues. We have started to release some of these presentations in partnership with the PCICS Podcast¹⁴, itself an innovation that has enriched the educational environment via another sensory mode of learning.

Clearly, if the current state has been this productive for educators in the pediatric cardiac intensive care space, the future is expected to be even brighter! Further refinement and development of each of the previously described endeavors will be necessary. Perhaps even more exciting will be the time when breakthrough innovations (eg. big data and predictive analytics platforms as used in some cardiac intensive care units) and disruptive innovations (eg. virtual and augmented reality as used in some morphology curricula and personalized surgical plans) become widespread, accessible tools to improve our clinical care and trainee education both nationally and globally.

Karl Migally, MD

Pediatric Cardiac Intensivist, Ann & Robert H. Lurie Children’s Hospital of Chicago

Assistant Professor of Pediatrics, Northwestern University Feinberg School of Medicine

Program Director, Pediatric Cardiac Intensive Care Fellowship, McGaw Medical Center of Northwestern University

kmigally@luriechildrens.org

http://www.linkedin.com/in/karl-migally

References:

1. Obituary, Hector R. Wong – https://www.cincinnati.com/obituaries/cen212521
2. In Memoriam: Hector Wong, MD, 1963-2022 – https://scienceblog.cincinnatichildrens.org/in-memoriam-hector-wong-md-1963-2022/
3. Maher KO, Chang AC, Shin A, Hunt J, Wong HR. Innovation in Pediatric Cardiac Intensive Care: An Exponential Convergence Toward Transformation of Care. World J Pediatr Congenit Heart Surg. 2015;6(4):588-596. doi:10.1177/2150135115606087
4. Tabbutt S, Ghanayem N, Almodovar MC, et al. Training fellows and residents in paediatric cardiac critical care. Cardiol Young. 2016;26(8):1531-1536. doi:10.1017/S1047951116002468
5. Anand V, Kwiatkowski DM, Ghanayem NS, et al. Training Pathways in Pediatric Cardiac Intensive Care: Proceedings From the 10th International Conference of the Pediatric Cardiac Intensive Care Society. World J Pediatr Congenit Heart Surg. 2016;7(1):81-88. doi:10.1177/2150135115614576
6. Kulik T, Giglia TM, Kocis KC, et al. ACCF/AHA/AAP recommendations for training in pediatric cardiology. Task force 5: requirements for pediatric cardiac critical care. J Am Coll Cardiol. 2005;46(7):1396-1399. doi:10.1016/j.jacc.2005.07.019
7. Feltes TF, Roth SJ, Almodovar MC, et al. Task Force 5: Pediatric Cardiology Fellowship Training in Critical Care Cardiology. J Am Coll Cardiol. 2015;66(6):712-722. doi:10.1016/j.jacc.2015.03.008
8. Bronicki RA, Allan CK, Costello JM, McBride ME, Tabbutt S for the PCICS Curriculum Writing Group:Curriculum for Pediatric Cardiac Critical Care Medicine: Physician and Simulation. Pediatric Cardiac Intensive Care Society 2017.
9. Migally K, McBride ME. Creating a Fourth-Year Pediatric Cardiac Intensive Care Fellowship Didactic Curriculum Using Educational Resources from the Pediatric Cardiac Intensive Care Society (PCICS). 2020 16^th Annual International Meeting of the Pediatric Cardiac Intensive Care Society (PCICS). https://www.eventscribe.com/2020/PCICS/fsPopup.asp?efp=S0NCTFlOWU8xMzAwOA&PosterID=317339&rnd=0.1786935&mode=posterinfo
10. Migally K, Matlin M, McBride ME. Creating a Local Pediatric Cardiac Intensive Care Simulation Curriculum Using Educational Resources from the Pediatric Cardiac Intensive Care Society (PCICS). 2020 16^th Annual International Meeting of the Pediatric Cardiac Intensive Care Society (PCICS). https://www.eventscribe.com/2020/PCICS/fsPopup.asp?efp=S0NCTFlOWU8xMzAwOA&PosterID=317338&rnd=0.1786935&mode=posterinfo
11. Tabbutt S, Krawczeski C, McBride M, et al. Standardized Training for Physicians Practicing Pediatric Cardiac Critical Care. Pediatr Crit Care Med. 2022;23(1):60-64. doi:10.1097/PCC.0000000000002815
12. Werho DK, DeWitt AG, Owens ST, McBride ME, van Schaik S, Roth SJ. Establishing Entrustable Professional Activities in Pediatric Cardiac Critical Care. Pediatr Crit Care Med. 2022;23(1):54-59. doi:10.1097/PCC.0000000000002833
13. Common Application: Consensus Statement from the PCICS Subcommittee of Pediatric Cardiac Critical Care Training Program Directors. https://pcics.org/programs/
14. Episode 58: PCICS Journal Club – Delirium in the CICU. In: PCICS Podcast. https://pcics.org/podcasts/