Deaths from congenital heart disease in childhood have fallen 83% in the last 25 years.1 This dramatic change has led to a significant increase in the numbers of adults with congenital heart disease (ACHD) requiring care, and prevalence is not expected to plateau until 2050.2 Even patients with extremely complex pathophysiology are now expected to survive well into adult life, and will have significantly higher rates of utilisation of all hospital services than the general population.3,4
The consultant workforce in ACHD in the UK is small, and faces substantial shortages. With very few trainees currently opting to train in ACHD, the workforce will fall even further behind, as patient numbers and complexity increase.5
A career in congenital heart disease – what does it offer the cardiologist?
A career in ACHD offers a professional lifetime of endless variation. In outpatients, you will see patients with infinitely variable anatomy and often complex physiology, over the course of many years, and through many medical and non-medical lifetime events. Fewer patients need inpatient care, and, when required, this is usually due to an acute arrhythmia, endocarditis or heart failure, cardiac or non-cardiac surgery or percutaneous intervention. Use of multi-modality imaging is an integral part of daily practice.
The ACHD cardiologist has to be something of a ‘generalist’, but this does not preclude further sub-specialisation within ACHD in intervention, imaging, electrophysiology and pacing, heart failure and end-of-life care, transition, pregnancy and pulmonary hypertension.
ACHD cardiologists work as part of a multi-disciplinary team alongside cardiac surgeons, specialist nurses, cardiac physiologists, physiotherapists, and psychologists.
For those with an academic orientation, there are research opportunities galore. Largely, thus far, an untapped resource, almost every question regarding ongoing care and management is unanswered, a dream for every budding academic.
If you choose a career in ACHD, one thing you will not be, is bored!
Core curriculum training – recent changes to curriculum
The general cardiologist is increasingly likely to encounter an acutely unwell ACHD patient while on-call. All cardiology trainees must be equipped with the knowledge-base and skills to manage the initial acute presentation, and know when to involve the specialist centre. Changes have been made to the core curriculum to ensure a broad knowledge-base.6 Trainees are encouraged to complete a free online core curriculum course,7 or attend an equivalent face-to-face course, and a dedicated two-week clinical attachment in a specialist surgical centre is recommended. This should take place as early as possible during ST3/4/5 to allow time for interested trainees to explore options for sub-specialty training. Trainees are also now required to upload a checklist to their e-portfolio as supportive evidence that they have achieved the basic competencies across the full range of conditions required to practise safely as a general cardiologist.
Prior to 2002, exposure to ACHD patients was piecemeal during general cardiology training, and sub-specialty training was a scarce resource.
In 2002, five national sub-specialty (ST6/7) ACHD training posts were established around already active centres in London, Southampton, Bristol, Birmingham and Leeds. These posts are advertised nationally and are open to anyone with a National Training Number (NTN) in either Adult or Paediatric Cardiology. Increasingly, there are also opportunities to pursue sub-specialty training in ACHD in a number of other centres via local arrangements. ACHD training at ST6/7 can consist of a module of four units (two years) – providing training in all aspects of ACHD for those aiming to work in a specialist centre, or two modules of ACHD (one year) can be combined with two modules in another sub-specialty, such as advanced imaging or heart failure, for those wishing to work as a consultant with an interest in ACHD.
Barriers to training
The numbers of applicants for sub-specialty ACHD training posts are small, and posts are at times left unfilled, increasing concerns regarding future manpower provision.
There appear to be a number of bars to trainees pursuing careers in ACHD. Some trainees are concerned that ACHD is ‘too difficult’ for them. Any trainee with a good understanding of cardiac physiology will come to realise quickly that ACHD is a science rather than a dark art, and once familiar with the subject, it is no more challenging than any other area in cardiology.
The five national sub-specialty posts are relatively thinly geographically spread and may only be advertised once every two years; it is easy for the interested trainee committed to one geographical area to miss out, simply by adverse timing. Negotiating through the out-of-programme-training (OOPT) process can be somewhat daunting if applying from out of region. Some individuals are counselled against ACHD sub-specialty training by well-meaning advisors who mistakenly believe ACHD is over-subscribed. Furthermore, some trainees are deterred because the geographic options open to them at the time of consultant appointment are likely to be more limited than for more general cardiology posts.
National structure of care and employment opportunities
The recent prolonged period of scrutiny of congenital heart services appears to be nearing conclusion. A new model and standards of care have been agreed by NHS England.8 The recommended structures rely heavily on implementation of regional and supra-regional clinical networks, with (usually) one specialist ACHD surgical centre (Level 1) acting as the central hub. Specialist ACHD centres (Level 2) aiming to provide the same level of expertise as Level 1 centres, require a significant commitment to ACHD from at least two cardiologists, but do not provide surgery or intervention. There may be a significant expansion in local ACHD centres (Level 3), which will require cardiologists with an interest in ACHD to work alongside cardiologists from the specialist ACHD centre.
ACHD offers a uniquely interesting and challenging career in cardiology, with opportunities to further super sub-specialise in particular areas of interest. We hope recent changes to the curriculum will expose trainees to an enhanced experience of ACHD earlier in their training, allowing them more time to arrange sub-specialty training in ST6/7.
Over the next few years there will need to be a significant increase in consultant workforce to cope with the rapidly increasing population, and also to fulfil the requirements of the NHS England standards of care. This includes specialist ACHD cardiologists (with at least two years ACHD experience in ST6/7) to work in Level 1 centres, but also cardiologists with expertise and interest in ACHD to work in Level 2 and 3 centres.
If you are interested in pursuing a career in ACHD, please contact the authors or the ACHD cardiologists at your local centre for more advice.
Conflict of interest
1. Townsend N, Bhatnagar P, Wickramasinghe K et al. Children and young people statistics 2013. British Heart Foundation: London, 2013.
2. Benziger CP, Stout K, Zaragoza-Macias E, Bertozzi-Villa A, Flaxman AD. Projected growth of the adult congenital heart disease population in the US to 2050: an integrative systems modelling approach. Popul Health Metr 2015;13:29. http://dx.doi.org/10.1186/s12963-015-0063-z
3. Van der Bom T, Mulder BJ, Meijboom FJ et al. Contemporary survival of adults with congenital heart disease. Heart 2015;101:1989–95. http://dx.doi.org/10.1136/heartjnl-2015-308144
4. Mackie AS, Pilote L, Ionescu-Ittu R, Rahme E, Marelli AJ. Health care resource utilization in adults with congenital heart disease. Am J Cardiol 2007;99:839. http://dx.doi.org/10.1016/j.amjcard.2006.10.054
5. Holdsworth D. Changes and challenges in cardiology training. BMJ Careers published online, 8 November 2012. Available from: http://careers.bmj.com/careers/advice/Changes_and_challenges_in_cardiology_training
6. Joint Royal Colleges of Physicians Training Board. Cardiology: about the specialty. Available at: http://www.jrcptb.org.uk/specialties/cardiology
7. Adult Congenital Heart Disease Learning Center. Available at: http://www.achdlearningcenter.org
8. NHS England. New congenital heart disease review: final report. Available from: https://www.england.nhs.uk/wp-content/uploads/2015/07/Item-4-CHD-Report.pdf