Educating and training new surgeons in congenital heart surgery, a highly complex surgical subspecialty with closely scrutinized outcomes, a steep learning curve, and numerous difficult procedures, presents considerable challenges. In this chapter, we examine the progress in surgical education relating to both adult cardiothoracic and congenital heart surgery and review innovative techniques that highlight the complexities of congenital heart anatomy. The “Boot Camp” experience introduces residents who are entering the field of heart surgery to synthetic and biologic simulation models of congenital heart disease [1]. Simulation‐based learning provides surgical residents with the opportunity to improve operative and cognitive skills, allowing for a more comprehensive educational experience [2]. Recently, specific simulation methods have been established for congenital cardiac surgery [3].

The current training paradigm for residents pursuing a career in congenital heart surgery has been described as a fellowship followed by a long‐term apprenticeship to attain technical facility. A 2006 poll concerning the training of congenital heart surgeons noted that graduating congenital heart surgery fellows did not feel adequately prepared to perform the more complex operations as the primary surgeon [4]. This led to a renewed interest in training methods and standards for congenital heart surgery [5].

In 2007, the American Board of Thoracic Surgery (ABTS) introduced a one‐year congenital heart surgery residency approved by the Accreditation Council for Graduate Medical Education (ACGME) that would follow successful completion of the traditional cardiothoracic surgery residency pathway [6]. The Congenital Cardiac Surgery Fellowship application process has been formalized via a match process under the aegis of the Thoracic Surgery Directors Association (TSDA), which allows applicants and program directors to consider every option for training without undue pressure being placed on either party. Institutions participating in the TSDA Congenital Cardiac Surgery Fellowship Match must be accredited by the ACGME. Training programs were vetted for accreditation based on surgical volume, educational commitment, and quality control [7]. Standards were imposed that required a minimal surgical caseload volume based on different levels of complexity that steadily developed technical prowess. The essential requirements for ABTS Congenital Cardiac Surgery subspecialty certification (as of December 2020) are listed in Table 49.1. Fulfillment of these criteria will result in a more mature diplomate who can perform congenital heart surgery independently [8]. In addition, the ABTS recently approved a two‐year congenital training program if the applicant and institution prefer that route to certification.

The Report of the 2010 Society of Thoracic Surgeons Congenital Heart Surgery Practice and Manpower Survey extensively reviewed the manpower status of congenital heart surgeons in North America [9]. Among the data considered were the estimated number of retiring surgeons from the workforce based on the reported survey:

Responses to the 2010 survey suggest that a minimum of 59 practicing congenital heart surgeons plan to retire over the next 10 years, and a total of 106 plan to retire over the next 15 years, for an average of about 7 per year. This is a minimum estimate that does not consider those who did not respond to the survey or did not answer the specific question. It also does not include projections of unplanned retirement for reasons of health, which were cited by 7 of 16 retired congenital heart surgeons who participated in the 2010 survey. [9]

This manpower assessment was confirmed in 2017, with 31 surgeons estimating ≤0.5 years to retirement [10]. A reasonable estimate is that approximately 8–10 new congenital heart surgeons per year would have to enter the workforce in North America in order to accommodate attrition rates owing to retirement, sickness, and early departure. This corresponds relatively well to the initial 12 ACGME‐accredited congenital surgery fellowships.

In 2016, Kogan and associates [8] performed a survey of ACGME Congenital Cardiac Surgery fellows and found reassuring data to support the idea that there has been considerable improvement in resident surgical training. In the survey 44 graduates of ACGME‐approved Congenital Cardiac Surgery programs who completed their training between 2008 and 2014 were queried about their experience and current practice patterns; 82% responded. Most trainees were satisfied with the operative experience during their surgical training, which was in stark contrast with the previous report from 2006 [4] concluding the opposite. Further, 84% of respondents are practicing congenital heart surgery, the majority of whom are in group practices (91%), which gives the opportunity of continued mentorship during the developmental stages of a congenital heart surgeon’s career path.

Nevertheless, challenges remain concerning the length of time in residency, the number of complex cases that are performed by congenital heart surgery residents, and the time in waiting for attending surgeons to become accustomed to the new resident [11]. There are numerous reasons for the time it takes for residents to develop operative skills, judgment, and mature temperament during the residency period. Increased scrutiny of outcomes from local and national organizations combined with a more educated population has made it more important than ever before to maintain the best possible outcomes. Because outcomes in congenital heart surgery have been repeatedly demonstrated to be proportional to surgical volume [12], there is a paradox: one must have experience to obtain good outcomes, but how does one gain experience while maintaining optimal outcomes? This dilemma is an important issue for both the attending surgeon and the resident in training. The dilemma extends into the early careers of congenital heart surgeons, which can represent a significant impediment to their development, and can limit the number of surgeons who feel comfortable with complex procedures.

It seems intuitively obvious that a one‐year congenital heart surgery residency, following a comprehensive cardiothoracic surgical residency, is still not enough time to learn the intricacies, multiple anatomic variations, and surgical skills that are required for a career in congenital heart surgery. In fact, some of the ACGME fellowships are changing to the newly approved two‐year fellowship. One can also infer that the quicker the resident is incorporated into all aspects of surgical training, the better will be the educational outcome. This educational dilemma, while improved significantly, is still the subject of continued evaluation [7, 11]. The following are newly introduced methods of cardiothoracic surgery education that highlight practical tools to help both trainees and mentors enhance and optimize the training experience.

“Boot Camp”

In 2008, the TSDA and ABTS organized a “Boot Camp” [1] at the University of North Carolina. This “Boot Camp” experience offered focused training to first‐year American cardiothoracic surgical trainees to prepare them for the technical challenges that will be encountered during their upcoming residency experience. Attention was focused on coronary anastomosis, cardiopulmonary bypass and cannulation, pulmonary resection, bronchoscopy and mediastinoscopy, as well as aortic valve surgery. Various high‐fidelity and low‐technology methods were used to simulate the educational process, which included porcine models (Figure 49.1) and a portable anastomosis station with synthetic target vessel (Figure 49.2). Subsequent documented experience emphasized the veracity and utility of the “Boot Camp” experience, with measured favorable evaluation by both trainees and faculty [2, 13–17].

Committed surgical educators formed the Cardiac Surgery Simulation Curriculum [2] at eight institutions from 2010 to 2013 and evaluated the results by a 68‐question survey. The survey included the evaluation of specific modules that reviewed the experience of 27 residents who were trained by 18 faculty members. Focused evaluation of each of the six training modules was assessed. The majority of residents and faculty indicated that resident operative skills and performance had improved. Both residents and faculty reported a favorable assessment of the training modules, which contributed to their comfort and ease in managing adverse events and crises [18, 19]. The authors of this study stated the following:

The operating room may no longer be the ideal location for early surgical training because of ethical concerns, time constraints, changes in resident work hours, hours necessitating more structured training, and more complex procedures performed on higher‐risk patients. In addition, cognitive and technical learning in the operating room provides little opportunity for practice and reflection. Simulation based learning thus can provide necessary training and practice outside the operating room. [1]

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