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SAN DIEGO -- Congenital heart surgeons are trying to revamp their profession by stiffening the rules for training and competency, with the goal being to better control the talent joining their ranks every year.

During the annual meeting of the (STS), they confronted the hard questions of whether they are training too many people, and if the community as a whole is not providing trainees and early-career surgeons with good mentoring.

Some congenital heart graduates said they have not found satisfying employment despite a long training path, and people who reported being dissatisfied tended to cite low case volumes as one factor.

A recent STS survey, published in , showed that of 201 practicing congenital heart surgeons who responded, nearly one in three had 100-149 cases annually, and a quarter of respondents reported performing fewer than 50 pediatric cases per year.

Half of working surgeons said their volume was "just right," whereas over 40% said theirs was "too small"; many people pegged the minimum number of operations to maintain competence at 100 per year, reported Stephanie Fuller, MD, of The Children's Hospital of Philadelphia, and colleagues.

Thus, Fuller and other speakers at the STS discussion suggested there are too many surgeons in the workforce spreading the pediatric congenital heart cases too thin.

The American Board of Thoracic Surgery (ABTS) currently requires surgeons to log 50 congenital cardiac surgeries a year for maintenance of certification -- already down from the 75 a year stipulated in the past.

The concern is how that can be maintained given the current workforce numbers. The survey by Fuller's group showed 30 people, or nearly 15% of respondents, reporting that they plan to retire in the next 5 years, or roughly six people per year. Meanwhile, there are more and more training spots each year, which currently sit at approximately 17.

In 2019, researchers estimated that the U.S. has more than double the number of congenital heart surgery centers that it needs.

Jennifer Romano, MD, MS, an ABTS director and a program director at the University of Michigan in Ann Arbor, argued for fewer congenital heart surgeons in the workforce.

This may be achieved with the upcoming change from the current training model. Beginning on July 1, the ABTS is mandating that all candidates for congenital cardiac surgery fellows will be required to complete 2 consecutive years in a single accredited program and complete 150 major cases (with a minimum of 50 major cases in the first year of training).

The new regulation stems from concern that trainees needed more cases and longer fellowships before entering the workforce. Until now, 1-year fellowships have required candidates to perform a minimum of 75 major pediatric congenital cardiac surgeries as primary surgeons. Many graduated just barely exceeding that threshold.

Yet regulation of training may be short-sighted, argued Paul Chai, MD, of Emory University and Children's Healthcare of Atlanta, who said the rules don't fix the issues inherent to the profession of congenital heart surgery (e.g., unchanging birth rates and a limited need for working surgeons).

Chai said it's not straightforward to answer the question of whether congenital fellowships should be limited, but it is critical to ensure consistent entry of high-quality surgeons for the future of the field and the benefit of patients.

He noted the deficit of applicants in recent years relative to the number of congenital heart programs approved by the Accreditation Council for Graduate Medical Education. With potential waning interest in the field, it doesn't help to limit the fellowships if the quality of the applicants isn't high, he said.

Fuller said it's unclear how congenital cardiac fellowship programs would handle the new training schedule: they have the option of enrolling fellows on an annual vs biennial basis -- perhaps splitting cohorts between odd and even years.

As for which centers will survive, there may be benefits to getting rid of the low-volume congenital heart programs that are unable to provide the same level of care as nearby regional programs, Romano said.

One way to organize centers would be with two tiers of centers with different requirements for staffing and case volumes, as proposed by new multisocietal consensus standards for pediatric heart surgery. The plan to divide institutions into essential care centers and comprehensive care centers has been approved by the Congenital Heart Surgeons' Society and is out for comment from professional society partners, Romano told the audience at the STS meeting.

"We should think about how to attract people in creative ways rather than how to limit them," Chai maintained.

Among his suggestions for the field is to rethink the paradigm that congenital heart surgeons should only do congenital cases early in their career; there may be sense in joining adult and pediatric surgery for some positions.

"Adult congenital is the only potential growing field that we have," Chai said. "We should think how we can use that -- [such as] an early career transition for these graduates."

The U.S. does not track the number of adults surviving with congenital heart disease, but this is believed to be a growing population due to neonatal and childhood treatment.

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