Although there is a consensus that echocardiography performed by neonatologists (TNE/NPE) and cardiac POCUS are both valuable in the management of neonates with cardiorespiratory failure, there is no widely accepted structure or process to acquire the skill and, more importantly, to verify competency.13 The expert opinion and consensus statements in the last decade have provided some framework and guidelines on training and quality assurance.

Some of the challenges in standardizing echocardiography training stem from the regional and institutional differences in the availability of resources and expertise to support a TNE or cardiac POCUS program. Although there are many courses and workshops on the subject providing the initial steps in learning echocardiography, one needs to spend at least 6–12 months as a mentored trainee to acquire the necessary TNE skills in obtaining images and interpreting the findings. This may be achieved during or after the neonatology fellowship (Fig. 2), the scope of which warrants further exploration as there is an increased demand to develop such skills and limited availability of the resources (trainees’ and mentors’ time and availability of the infrastructure).

The pros and cons of learning neonatologist performed echocardiography during and after neonatal fellowship training are shown.

Training during the fellowship has several advantages. Fellows have three years to learn and to be evaluated. If TNE becomes a part of fellowship training, the impact on the expansion of echocardiography knowledge and skills in the neonatology workforce and, by extension, on neonatal patient care will be highly significant. Ideally, basic principles and use of ultrasound should be taught in medical school and be included in the pediatric residency curriculum so that incoming fellows have some basic knowledge of POCUS/TNE. However, there are several limitations. Although increasing, the number of fellowship programs with the infrastructure and expertise to support a fellowship TNE program is still low. Even in the programs with TNE expertise, the demand for substantial time commitment from the TNE faculty poses a significant barrier, especially in smaller programs where only one or two TNE experts are on staff. The other challenge is completing neonatology learning objectives for the fellow in a timely manner.

Here, we briefly describe some of our experiences training neonatology fellows in our programs. At Los Angeles County Hospital, the University of Southern California, and Children’s Hospital Los Angeles, opportunities for learning echocardiography for neonatology fellows have existed since 2000. The echocardiography training has evolved over the years. In 2003, the first annual functional echocardiography course was held. Both neonatologists and cardiologists taught this 5-day course on ultrasound physics, imaging, and hemodynamics. Although our fellows were the primary target audience, the attendees included local, national, and international neonatologists and physicians in training. Since 2012, we have added echocardiography simulator training to enhance and accelerate the initial skill development.14 The fellows are required to attend the annual course in the first year of their fellowship. The post-course training has changed from an elective to mandatory since 2018. Each fellow is required to spend two weeks a year dedicated to learning echocardiography. This involves hands-on training on the simulator, performing echocardiography in the newborn nursery and NICU, and observation and case discussion in the echo lab. The simulation training prepares the fellow for the actual echocardiography and is especially important for the novice, although it is helpful for the more advanced learners.15 In addition, the trainees can improve their skills in differentiating normal from abnormal heart structure by imaging over 30 cases of various CHD cases on the simulator. Depending on the competency level, they will perform TNE throughout the year. A member of the TNE program with expertise in echocardiography or a pediatric cardiologist reviews each echocardiography study. By the end of the fellowship, each fellow has done over 100 complete echocardiograms. In addition, fellows participate in monthly hemodynamic case conferences and quality improvement meetings, where they learn the interpretation of echocardiography images and how this knowledge can be applied in clinical practice.

This can be in the form of an additional year of fellowship dedicated to echocardiography and hemodynamics or a less structured and perhaps with a more limited scope for the practicing neonatologist. The first one-year hemodynamic fellowship program was established at the University of Iowa in 2019, with few other programs offering similar programs since. This approach had some advantages over training during the neonatology fellowship. The whole year is dedicated to learning TNE, understanding hemodynamics, and applying the knowledge in daily patient care. These programs typically have leading hemodynamic experts on the faculty and a robust supportive infrastructure. The graduates from these programs are expected to master TNE and continue developing hemodynamic expertise. However, this approach in training also has limitations. Typically, the programs take one fellow a year, and since there are only a handful of such programs, currently the impact of such training on spreading skills among neonatologists is limited. However, given the selection process for the most dedicated candidate and the comprehensive curriculum, the graduates from these programs are likely to have greater potential to initiate and establish a TNE program after graduation.

Recruiting experts in TNE and providing them adequate time to introduce the concept to pediatric residents and provide dedicated training to fellows requires a financial commitment from the Departments of Pediatrics for both models. The additional year of advanced hemodynamics fellowship is currently not approved by ACGME and will require funding from Departments although these providers have the option of “moonlighting” and earn extra-service payments. Finally, an incentive (higher salary, guaranteed protected time, or earlier promotion to a higher rank) must be provided to graduating neonatal trainees with expertise in TNE.

With proposals to reduce time spent in the ICUs by ACGME,16 incoming fellows to neonatal-perinatal medicine are likely to need longer clinical time to achieve basic neonatal skills such as resuscitation, line placement, and intubation. The added burden of learning and developing expertise in TNE may limit the time available for scholarly activities in the “training during fellowship” model.

The recent suggestion by the National Academies of Science, Engineering, and Medicine (NASEM) to reduce the duration of pediatric fellowships to two years for clinically focused providers may lead to less time for additional TNE training during fellowships and support the “training after fellowship” model. However, the main focus of the NASEM report was pediatric subspecialties with difficulties in recruitment such as infectious diseases and endocrinology, and not neonatal perinatal medicine.17

Close attention should be paid to these proposals and their implementation as it is likely to impact the time available for TNE training.