Demographic Information

In total, 6 participants from CHI and 20 from TCH were invited to participate. Fourteen fellows (54%) participated in the study. Ten fellows (71%) were from Texas Children’s Hospital, all of whom were originally from the USA, while four were from Children’s Health Ireland (29%) all of whom were originally from Ireland. The first 4 years of fellowship were evenly distributed with 4 fellows in year 1 and 3 in years 2–4; there was one fellow in year 5. Median number of sessions attended was 5 (interquartile range 3–6).

Utility of Joint Sessions

The closed questions related to the joint educational sessions and their responses are listed in Fig. 2 and Table 2. The majority (93%) found the sessions helpful from an educational standpoint, with the remainder neutral (7%). Respondents were asked to rank 10 session topics in order of their utility. The topics are listed in Table 2. The highest ranked session was a discussion of anonymized clinical cases of ventricular septal defects which differed in their management between the USA and Ireland, while the second highest ranked session dealt with the management of aortic atresia with VSD and normal biventricular dimensions. Both aimed to generate constructive debate and highlighted complex management decisions with elements of clinical uncertainty. Respondents were asked to rank what they found to be the most useful component of the sessions (Table 2) and the discussion was ranked highest. The majority (71%) of respondents agreed that the sessions highlighted areas of clinical uncertainty in practice. Fellows were asked multiple choice questions on management of clinical case vignettes. Their responses are depicted in Figs. 3 and 4. Notable is the variation in practice among the group on the optimal approach to patient management.

Fig. 3

Management of the infant with Tetralogy of Fallot and significant cyanosis. *Ductal stent if ductus remains open

Fig. 4

Management of neonatal aortic stenosis

Challenges and Areas for Improvement

All responses are listed in Table 2. Fifty percent of respondents found it difficult finding time to attend sessions. The majority (81%) cited clinical commitments as the main barrier to attendance, with conflicting schedules. An aim of the sessions was to stimulate fellows to develop a research question (either between institutions or individually). Twenty-nine percent agreed that the sessions had inspired a research question, while 50% disagreed. Respondents provided free-text commentary on suggested changes and improvements to the session. More frequent sessions, utilization of technology-enhanced learning solutions, and fellow-led sessions were suggested. Eighty-six percent agreed or strongly agreed that this model of learning could be extrapolated to other international centers. Sixty-five percent of respondents agreed that involving other centers (for example, from South America, Asia, or Australia) would strengthen their experience of the program as a learner.

Fellows as Learners

The respondents were asked closed questions regarding their experience as learners throughout their training with responses listed in Table 3. When asked to rank learning resources by utility the highest ranking was clinical practice itself. The lowest ranking was work-based assessments. Final-year fellows were asked if they felt ready to transition to faculty practice. 66% percent agreed or strongly agreed, while 33% were neutral.

Qualitative Analysis

Following two rounds of inductive, consensus and descriptive style coding conducted by two authors, saturation was reached after 12 interviews. 34 individual codes were identified. From the 34 codes, 3 central themes were derived which were practice variation; managing uncertainty; and cognitive overload.

Practice Variation

The concept that the educational experience of the fellows was enhanced by the contrasting practices of the other institution emerged as a clear theme from within the responses. Respondents were asked to provide commentary on the practice in the other institution. Participants noted the variation in practice between the two centers. Specifically highlighted was a preference for interim and definitive catheter-based interventions over surgical techniques in Dublin when compared with Texas. Several trainees cited right ventricular outflow tract stenting compared with BTT shunt in the management of Tetralogy of Fallot. Fellows noted a preference for earlier surgical repair of ventricular septal defects in Texas when compared with Dublin. Also noted was the institutional preference in Texas for infants with high-risk lesions such as hypoplastic left heart syndrome to remain in hospital between stages 1 and 2. Fellows from both institutions emphasized that they had never considered the management practices of the other institution. There was a sense of mutual respect in the commentary. Neither expressed criticism of the other’s practice but rather saw it as an alternative means of providing excellent care.

“Centers may practice things differently for different reasons but ultimately have similar results”

Cultural differences (for example, patient’s choice of their physician in Texas) and resources (comparatively fewer in Dublin) were suggested as sources of practice variation.

“It was nice to see another center, which is bigger than ours, doing things similarly and validating for me personally that I am achieving a good standard of training for my future career.”

Cognitive Overload

The theme of cognitive overload was expressed by learners in discussing the challenges facing during their fellowship.

“….trying to absorb as much as I can but knowing I’m at the tip of the iceberg”

Time management (in balancing arduous clinical commitments with research, scholarship, and home life) was frequently referenced. Learners additionally perceived the breadth of material required to be a significant obstacle.

“Trying to better grasp some of the more granular details that factor into decision making, my default is generally to defer to the opinions of my supervisors or those with more experience.”

Managing Uncertainty

The theme of uncertainty, and how to manage it, was common across several lines of questioning. Firstly, regarding the challenges fellows faced in training, cited was the complexities of working in a field with limited randomized control trial evidence.

“It was challenging how often we came back to the lack of good evidence regarding many of our clinical decisions in pediatric cardiology.”

This was a source of clinical uncertainty. Participants also referenced uncertainty in their career and their path to becoming a consultant/attending. Individual codes within this theme were the sense of imposter syndrome and concerns around job security. Promisingly, free-text commentary from final years when compared with other participants referenced an embrace of the uncertain;

“Not there yet, but I think I will feel that ‛one never feels ready’ and that having the modesty to accept that even once finished training you are always learning.”

Concept Map

A concept map (Fig. 5) was created to encapsulate the key findings of the questionnaire.

Fig. 5

Conceptual map of international pediatric cardiology fellowship twinning