What Makes An Effective Chief of Pediatric Cardiology: Insights From Chiefs of Programs Globally

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Kim, Lars Idorn, Sandra S. Mattos, Worakan Promphan, and 14 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6942966/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Aug, 2025 Read the published version in Pediatric Cardiology → Version 1 posted 18 You are reading this latest preprint version Abstract Background While the position of a pediatric cardiology chief is seen as the apex of one’s academic career, its roles, responsibilities, and qualifications are not well defined in literature. We previously surveyed North American pediatric cardiology chiefs to characterize these qualities. It is not known if these findings apply across programs around the world. Objective This study was done to gain further insight of the role and attributes of a pediatric cardiology chief beyond North American programs by surveying those who are currently serving the position around the world. Methods This was a mixed-methods study that sent a survey out to pediatric cardiology chiefs from around the world. The survey was a semi-structured questionnaire independently reviewed by three cardiologists. The survey included items rated on a 5-point Likert scale, open-ended prompts, and targeted questions regarding the chief’s role and qualifications. Results 31 pediatric cardiology chiefs from 22 countries completed the survey. The 4 most important traits for the role of chief included communication, honesty, work ethic, and management skills. 60–75% of responses reported a change in faculty and trainee work ethic. 50–60% of responses also reported increased expectations from patient families and hospital administration. Thematic analysis on the challenges and success of running a department revealed the importance of developing a team and needing a strong sense of self and responsibility for the team. Conclusion We gathered information directly from current pediatric cardiology chiefs from around the globe examining the current era of its role. Awareness of such key attributes may help promote effective leadership skills as chiefs of pediatric cardiology. Congenital Heart Disease Chief Leadership Pediatric Cardiology Program Collaboration Figures Figure 1 Figure 2 Introduction The chief position is often the pinnacle of one’s academic career in medicine [ 1 – 4 ]. Little is documented in the literature with regards to the role responsibilities, skill requirements, and characterization of who is fit best to lead. The role of chief is a pivotal role in establishing departmental culture, developing their faculty, and ensuring the department is providing excellent patient care [ 5 , 6 ]. We previously examined attributes and challenges North American pediatric cardiology chiefs reported and the evolution of the role particularly with differing healthcare models, program expansion, revenue targets, achieving excellence in patient outcomes, and ongoing collaboration with subspecialties and corporate suite models [ 7 – 11 ]. We were interested in expanding our query to determine if these qualities resonated with other international pediatric cardiology chiefs. We sought to assess how differing healthcare systems, governments, and cultures could potentially influence the position [ 12 , 13 ]. Methods This was a mixed-methods study with grounded theory employing both quantitative and qualitative components using a semi-structured questionnaire which was approved by three independent pediatric cardiologists trained in medical education. This was utilized in a prior study focused on North American pediatric cardiology chiefs [ 1 ]. This survey was created in SurveyMonkey to aid ease of completion by respondents. Invitations to participate in the survey were distributed via email to pediatric cardiology chiefs identified across North America, South America, Europe, South Asia, and Australia/New Zealand. Programs and individuals were invited semi-randomly to achieve proportional representation of pediatric cardiology centers globally. Need for consent to perform this study was waived by the Ethics department at Children’s Health Ireland (Crumlin, Dublin, Ireland). Consent was requested from all respondents to complete the survey and to facilitate the results of the study being disseminated in a peer-reviewed pediatric cardiology journal. Surveys provided the option for respondents to be identified if they wished to be acknowledged. All survey data was stored securely in a password protected document accessible only by the study team. Statistical Analysis Demographics and descriptive statistics including Likert scale responses from the survey were summarized by medians with interquartile ranges and frequencies with percentages. Within the survey, participants ranked items which were then calculated by means with standard deviations. The open-ended prompts were manually coded by two independent reviewers which then were compiled into themes. Results Demographics The survey was distributed to chiefs in pediatric cardiology centers around the world. Demographics included the number of years in practice as a pediatric cardiologist, number of years serving as pediatric cardiology chief, and whether this was their first chief position (Table 1 ). In total, 31 chiefs representing 22 countries responded. Approximately 23% (7) of respondents were female. Table 1 Participant demographics. Item Participants %, (n = 31) Program Location, % (n) Australia 3 (1) Brazil 6 (2) Canada 3 (1) Denmark 6 (2) France 3 (1) Germany 3 (1) Hong Kong 3 (1) Iceland 3 (1) India 3 (1) Italy 10 (3) Ireland 3 (1) New Zealand 3 (1) Norway 3 (1) Pakistan 3 (1) Romania 3 (1) Slovakia 3 (1) Spain 3 (1) South Africa 3 (1) Sweden 3 (1) Thailand 3 (1) United Kingdom 13 (4) United States 10 (3) Years in practice, median (IQR) 24 (18, 30) Years served as chief, median (IQR) 5 (3, 13) First time position, % (n) 90 (28) Cardiopulmonary bypass cases a year 101–250 32 (10) 251–400 42 (13) 401–600 10 (3) 601–800 10 (3) 801–1000 3 (1) Department faculty size, median (IQR) 11 (7, 21) Key Attributes of Effective Chiefs The survey tasked participants to rank a list of traits in order of importance for the pediatric cardiology chief role (Table 2 ). In summary, the top 4 traits were similar in ranking to the North American pediatric cardiology chiefs in prioritizing communication skills, honesty, hard-working, and management skills. Interestingly, the data diversified in the global survey with a larger parity in ranking of traits after the top 5 compared to the North American chief responses aside from “Teacher” and “Reputation” also being ranked last. Table 2 Average ranking of traits important for pediatric cardiology chief role (1 = most important, 14 = least important). Item Average Rank (SD) Communication skills 2.9 (2.2) Honesty 3.2 (2.8) Hard-working 5.5 (3.1) Management skills 6 (2.9) Equitable treatment 6.5 (3) Effective negotiator 8.6 (3.4) Decisive 9 (3.8) Academic excellence 9 (4) Promoting psychological safety 9.2 (3.7) Self-awareness 9.2 (4.1) Conflict resolution 9.4 (3.4) Humility 9.5 (4.4) Visionary 9.5 (4.4) Teacher 10.8 (3.3) Reputation 11.5 (3.7) Table 3 Responses pertaining to chief position longevity and succession. Item Response, % (n) Yes Depends No Should the chief position rotate every 5–10 years? (n = 29) 48 (14) 28 (8) 24 (7) Do you believe succession planning is important as a part of the chief role? (n = 30) 90 (27) - 10 (3) If you started your career over, would you serve as chief again? (n = 31) 94 (29) 3 (1) 3 (1) Do you think formal management education (i.e. MBA) is important to be effective in the role? (n = 29) 41 (12) - 59 (17) When combining these rankings with open-ended responses there were clear categories which were organized amongst the global chief participants which were organized based on the various responsibilities and facets of a cardiology chief (Fig. 1 ). Specifically, the lists were also organized in descending order from the most commonly referenced items within each category. Likert Scale Responses Survey items were rated on a 5-point scale which is summarized in Figs. 2 a and 2 b. Respondents reported satisfaction in their tenure as chief. Compared to data from North American chiefs [ 1 ], participants did not appreciate higher expectations from faculty and managing the department although they recognized higher pressure from patients/families and the corporate suite. Like the North American counterparts, there is a similar commentary of changes in work ethic amongst faculty and trainees which was cited as mainly due to more emphasis on work-life balance with several clarifications that this was not a bad thing. Finally, when tasked in responding about items pertaining to program expansion and program ranking, global respondents did not resonate with these items compared to North American counterparts and faced different challenges (i.e. staffing issues, different healthcare system models). Qualitative Prompts and Themes We also included open-ended questions like our other survey design in determining the priorities, challenges, and benefits of serving in the role of a pediatric cardiology chief amongst a global audience. Two main themes emerged from the coded data which included: 1) Building and developing a well-functioning team is essential for long-term success of the program; 2) The role requires a strong sense of self and responsibility to others as well as oneself in terms of knowing one’s limitations and strengths. The first theme overwhelmingly was repeated by participants in terms of stressing the importance of teamwork, building a well-functioning team, and the challenges of managing a dysfunctional team which all contribute to the outcomes of a program. These include the responsibilities of the chief recruiting and hiring the right people as well as being responsible for developing faculty and the culture of a program well. It is also important that a recurring item with this theme also included the need to bring a team together in a single vision/mission. ...To establish a [program] where colleagues feel welcome and are devoted to aim for the highest clinical and scientific standards within pediatric cardiology… “...Choose your best team. Realize who has the potential and how to achieve the best results as a team. Make everybody shine - see the potential in your employees, give them time and room to evolve…“ ...Keeping a big team happy and together is difficult! Be visible and approachable. Be kind… ..Building a team is more important than excellence. A mixed team of both sexes is important. Different personalities are needed in different areas of cardiology… ...Developing and sustaining a harmonious team is the most critical aspect of running a pediatric heart program…all the members of the team should deeply resonate with the mission and vision of the program that needs to be articulated with great clarity… The second theme resonated with much more introspective insights from respondents that emphasized elements that were not readily visible to their team members or patients. It became more apparent that the need to self-actualize is a crucial step in developing a leadership style and ability to lead. ...Be loyal to yourself and your team. Fight for what you think is the best for your team and the patients - even if [others] want you to do differently. Do not be afraid or hesitate to take an unpleasant decision if you know or think it is the right thing to do… ...Leadership can only be sustained if the leader leads by example… Interestingly, while not as high of a frequency in responses to warrant a third theme, there were many comments surrounding the clinical competency and skills as a physician that respondents felt were important in being a successful chief: ...The essential attributes would include high degree of clinical competence, excellent communication and teaching skills, a deep understanding of what it takes to be a good mentor, an excellent grasp on the healthcare landscape of the region…it is also important to develop excellent working relationships with other providers… ...be a very good doctor in pediatric cardiology, probably the best...be a good leader…be capable of coordinating a team… be an example for others… ...I think the perfect chief needs professional insight broadly in pediatric cardiology as well as good leadership abilities… Discussion Despite the wide range of program sizes, models, and healthcare systems compared to the North American model [ 1 ], there were a lot of similarities when assessing key attributes for the pediatric cardiology chief role with the main crux revolving around communication and interpersonal skills (Table 2 ). There was a higher emphasis from the global counterparts on a leadership model emulating more similarly to a “role model” as opposed to a “servant leader” which was more common in North American programs, emphasizing the need for clinical expertise in the field. In fact, “servant leader” was seldom mentioned at all amongst global respondents outside of North American programs. There was an emphasis on the challenges and pressures of the chief position for program excellence which stemmed from the ability of a team to function at a high level. This is again dissimilar from the North American counterparts where they felt the push for program excellence was propagated by the need for program expansion. It is reassuring that ultimately respondents were very satisfied with the role regardless of nationality or program structure which again emphasizes that the role possesses more positive outcomes than detriments. In terms of succession planning, while there was near unanimous sentiment in its importance, there was less clarity in the need for term limits. When examining open-ended comments these responses were reinforced by the justification that excellent chiefs should be given the opportunity to serve longer than anticipated should the group agree to do so rather than be forced to turn the role constantly. When examining how to best construct the “perfect” pediatric cardiology chief from the data provided there is a heavy emphasis on the chief’s ability to build and develop a team with strong interpersonal skills in addition to clinical excellence to lead by example. It should also be acknowledged that like prior studies, there is a continued lack of representation in leadership with respect to diversity, equity, and inclusion [ 1 , 14 – 22 ]. While certainly those most fit for the role are the ones who take the position, there is invariably both conscious and unconscious biases influenced by culture (workplace and societal) and interpersonal dynamics that should be a consistent reminder increased sensitivity so that those in influential leadership positions, whether it is a pediatric cardiology chief or even editorial boards, are representative of the population and workforce at large [ 23 ]. Since the Covid-19 pandemic, international collaboration and communication has risen dramatically which opens several new potential opportunities within pediatric cardiology. For a highly subspecialized field, shared information and practices can continue to advance the field and create dialogue which often may occur at the direction of the chief. Proper leadership education, training, and intentionality is important to build functioning partnerships globally [ 24 ]. We therefore have proposed several components for ongoing efforts on a global scale for pediatric cardiology programs and chiefs to address our findings: Proposed Supports for Chiefs of Pediatric Cardiology Programs : Greater research on the role of the chief position globally including leadership training, education, and collaborative efforts Increased support for women in leadership roles and sensitivity to diversity, equity, and inclusion efforts Development of formal workshops to facilitate forums in which chiefs can share challenges with the role Establishment of regular online meetings for chiefs to discuss challenges and successes Innovation in pediatric cardiology fellowship education with tracks for those interested in administration and leadership Limitations There are several limitations that should be acknowledged in this study. This questionnaire, while reviewed by multiple cardiologists, is not a widely validated instrument as one does not currently exist [ 1 ]. We expanded the voice of the chiefs in this study by expanding the scope of programs on a global scale – we did not completely capture every country nor did we achieve a high number of respondents although we attempted to control the representation from certain regions due to the number of programs. While the perspective of the chiefs is highly valued in this research question, other stakeholders within the department are likely just as important (i.e. faculty). Conclusion We discovered the role of pediatric cardiology chief is widely variable on a global scale. There were enough differences highlighted to challenge the notion that while North American programs academically represent an archetype for clinical excellence, there is much to be gained and appreciated from a global perspective. Further studies can examine these similarities and differences at a deeper level whether that is direct comparison of different healthcare models, program structure, and center volume. Declarations The authors have no relevant financial disclosures or conflicts of interest with the study. Author Contribution M.K. and C.M. wrote the main manuscript of the text and prepared the figures/tables. All authors reviewed the manuscript and provided important feedback for the study. Acknowledgement We are grateful to Dr. Tara Bharucha, University Hospital Southampton, United Kingdom; Dr. Gianfranco Butera, Ospedale Bambino Gesù Roma, Italy; Dr. Giovanni Di Salvo, University Hospital of Padua, Italy; Dr. Gabriela Doros, Louis Turcanu Emergency Children’s Hospital, Timisoara, Romania; Dr. Ulrike Herberg, University Hospital RWTH Aachen, Germany; Dr. Lily Montalvan, Hospital Infantil Sabara, Brazil; Dr. Gylfi Óskarsson, National University Hospital of Iceland, Iceland; Dr. Michael Rahbek Schmidt, Rigshospitalet, Copenhagen, Denmark; Dr. Juan Ignacio Zabala Argüelles, Hospital Materno Infantil de Málaga, Spain; Dr. Martin Zahorec, Pediatric Cardiac Center, National Institute of Cardiovascular Diseases, Slovakia for their participation in the study. References Kim ME, Franklin W, Dubin AM et al (2024) What makes an effective chief of Pediatric Cardiology: insights from chiefs of North American pediatric programs. J Am Heart Association. ; pe036908 Lederer E (2018) Leadership as a division chief of nephrology. Adv Chronic Kidney Dis 25:480–484 Tauben D (2017) Interview with David Tauben: University of Washington, chief of the division of pain medicine. Pain Manage 7:233–238 Medina-Walpole AM, Sachs GA, Hazzard WR (2020) Chief to chief: reflections on cultivating the next generation of geriatrics program leaders. Journal of the American Geriatrics Society. 2020; 68: 2759–2763 McMahon CJ, Sendžikaitė S, Jegatheeswaran A et al (2022) Managing uncertainty in decision-making of common congenital cardiac defects. Cardiol Young 32:1705–1717 Ryan A, Duignan S, Kenny D, McMahon CJ (2018) Decision making in paediatric cardiology. Are we prone to heuristics, biases and traps? Pediatr Cardiol 39:160–167 Duignan S, Ryan A, O'Keeffe D, Kenny D, McMahon CJ (2018) Prospective analysis of decision making during joint cardiology cardiothoracic conference in treatment of 107 consecutive children with congenital heart disease. Pediatric Cardiology. ; 39: 1330–1338 McMahon CJ, Hickey EJ, Nolke L, Penny DJ (2023) Organizational culture as a determinant of outcome in teams: implications for the pediatric cardiac specialist. Pediatr Cardiol 44:530–539 Caddell AJ, Wong KK, Barker AP, Warren AE (2015) Trends in pediatric cardiology referrals, testing, and satisfaction at a Canadian tertiary centre. Can J Cardiol 31:95–98 Morrison ML, McCrossan BA, Sands AJ, Craig B, Casey FA, Grant B (2016) Referrals to pediatric cardiology outpatients: continued evidence of increasing workload. Clin Pediatr 55:1346–1349 Kutty S, Delaney JW, Latson LA, Danford DA (2013) Can we talk? Reflections on effective communication between imager and interventionalist in congenital heart disease. J Am Soc Echocardiogr 26:813–827 Weil TP (2013) Health management education in Europe and in the United States: a comparative review and analysis. Health Serv Manage Res 26:76–85 Midttun L, Hagen TP (2006) The private-public mix of healthcare: evidence from a decentralised NHS country. Health Econ Policy Law 1:277–298 Friedman AH (2019) Talent alone is not enough: lessons learned in a decade as chief. Curr Opin Cardiol 34:87–93 Meadows AM, Skinner MM, Hazime AA, Day RG, Fore JA, Day CS (2023) Racial, ethnic, and sex diversity in academic medical leadership. JAMA Netw Open 6:e2335529–e2335529 Yedidia MJ, Bickel J (2001) Why aren't there more women leaders in academic medicine? The views of clinical department chairs. Acad Med 76:453–465 Capers IVQ, Johnson A, Berlacher K, Douglas PS (2021) The urgent and ongoing need for diversity, inclusion, and equity in the cardiology workforce in the United States. J Am Heart Association 10:e018893 Ezeoke OM, Williams J, Ogueri V, Hills BK (2023) The heart of the matter: a path to building diversity in pediatric cardiology. Pediatr Cardiol 45:1364–1371 Khan MS, Usman MS, Siddiqi TJ et al (2019) Women in leadership positions in academic cardiology: a study of program directors and division chiefs. J Women's Health 28:225–232 Eshtehardi P, Bullock-Palmer RP, Bravo-Jaimes K et al (2022) Women leaders: transforming the culture in cardiology. Open Heart 9:e001967 Balasubramanian S, Pasquali SK, Cousino MK et al (2023) Representation of women and minority faculty and fellows in academic pediatric cardiology training programs. J Am Coll Cardiol 81:1181–1188 Chowdhury D, Bansal N, Ansong A et al (2024) Mind the gap! Working toward gender equity in pediatric and congenital heart disease: present and future. J Am Heart Association 13:e032837 Dunne E, Zuhlke L, Kumar RK, Casey FA, Penny DJ, McMahon CJ (2022) Editorial board composition among pediatric cardiology journals: time to cast the net wider. JACC: Adv 1:100137 Matlow, A., Chan, M. K., Bohnen, J. D., Blumenthal, D. M., Sánchez-Mendiola, M., de Camps Meschino, D., … Busari, J. (2016). Collaborating internationally on physician leadership education: first steps. Leadership in health services, 29(3), 220–230. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Aug, 2025 Read the published version in Pediatric Cardiology → Version 1 posted Editorial decision: Revision requested 08 Jul, 2025 Reviews received at journal 07 Jul, 2025 Reviews received at journal 07 Jul, 2025 Reviews received at journal 05 Jul, 2025 Reviews received at journal 04 Jul, 2025 Reviews received at journal 04 Jul, 2025 Reviewers agreed at journal 03 Jul, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviews received at journal 26 Jun, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers agreed at journal 24 Jun, 2025 Reviewers invited by journal 24 Jun, 2025 Editor assigned by journal 24 Jun, 2025 Submission checks completed at journal 24 Jun, 2025 First submitted to journal 21 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Krishna Kumar","email":"","orcid":"","institution":"Amrita Institute of Medical Sciences and Research Center","correspondingAuthor":false,"prefix":"","firstName":"R.","middleName":"Krishna","lastName":"Kumar","suffix":""},{"id":477076404,"identity":"4fc33ff9-fc2c-4853-a038-43929e1b3ac0","order_by":16,"name":"Joseph Rossano","email":"","orcid":"","institution":"Children’s Hospital of Philadelphia","correspondingAuthor":false,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Rossano","suffix":""},{"id":477076405,"identity":"2f14aa41-1370-42b1-a413-7ae70658c127","order_by":17,"name":"Colin J. McMahon","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYLACxgYGBn725gMHEnhsGBgkiNUi2XMs8cEHmTQStBjcyDE2nGFzmLAW/mmHn274ucMmz+BGgpk0T875xP7ZzQcfMNTYROPSInE7zexm75m0YskzD9Kkec7cTpxx51iyAcOxtNwGHFoMpHPYbvC2HU7sO55wTJq353Ziw40cMwnGhsN4tdz8C9TScCCxTZr337nE+cRouQ2yZcKJZGbDGTwHEjcQ0gLyy23ZtrTEmT3HGB984Ek23ngjLdkgAY9f+GcnP7v5ts0msZ+9/wMwKu1k591IPvjgQ40NTi0YwBGsMoFY5SBgT4riUTAKRsEoGBkAAJ28aK1VwLJcAAAAAElFTkSuQmCC","orcid":"","institution":"Children’s Health Ireland","correspondingAuthor":true,"prefix":"","firstName":"Colin","middleName":"J.","lastName":"McMahon","suffix":""}],"badges":[],"createdAt":"2025-06-21 06:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6942966/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6942966/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00246-025-04002-4","type":"published","date":"2025-08-22T15:56:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85826287,"identity":"48a12388-c9f1-4dde-bb27-fff77cfd6b50","added_by":"auto","created_at":"2025-07-02 07:13:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":121994,"visible":true,"origin":"","legend":"\u003cp\u003eSchema of important attributes and duties of a pediatric cardiology chief\u003c/p\u003e","description":"","filename":"figure1final.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6942966/v1/630f9ee94e8a74329a144cdf.jpg"},{"id":85826282,"identity":"580a8f33-d88e-4613-95ac-ded057108bca","added_by":"auto","created_at":"2025-07-02 07:13:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":533768,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e2a and 2b. \u003c/strong\u003e5-point Likert scale survey responses on chief position and perceptions.\u003c/p\u003e","description":"","filename":"figure2a.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6942966/v1/02fdf4c80845b2151f71d450.jpg"},{"id":89847231,"identity":"36d9f495-24ee-4564-a5d5-be010954ffa9","added_by":"auto","created_at":"2025-08-25 16:42:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1283596,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6942966/v1/3ccd9938-d5a4-4411-8787-bfe94e10bd10.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"What Makes An Effective Chief of Pediatric Cardiology: Insights From Chiefs of Programs Globally","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe chief position is often the pinnacle of one\u0026rsquo;s academic career in medicine [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Little is documented in the literature with regards to the role responsibilities, skill requirements, and characterization of who is fit best to lead. The role of chief is a pivotal role in establishing departmental culture, developing their faculty, and ensuring the department is providing excellent patient care [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. We previously examined attributes and challenges North American pediatric cardiology chiefs reported and the evolution of the role particularly with differing healthcare models, program expansion, revenue targets, achieving excellence in patient outcomes, and ongoing collaboration with subspecialties and corporate suite models [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe were interested in expanding our query to determine if these qualities resonated with other international pediatric cardiology chiefs. We sought to assess how differing healthcare systems, governments, and cultures could potentially influence the position [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a mixed-methods study with grounded theory employing both quantitative and qualitative components using a semi-structured questionnaire which was approved by three independent pediatric cardiologists trained in medical education. This was utilized in a prior study focused on North American pediatric cardiology chiefs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This survey was created in SurveyMonkey to aid ease of completion by respondents. Invitations to participate in the survey were distributed via email to pediatric cardiology chiefs identified across North America, South America, Europe, South Asia, and Australia/New Zealand. Programs and individuals were invited semi-randomly to achieve proportional representation of pediatric cardiology centers globally. Need for consent to perform this study was waived by the Ethics department at Children\u0026rsquo;s Health Ireland (Crumlin, Dublin, Ireland). Consent was requested from all respondents to complete the survey and to facilitate the results of the study being disseminated in a peer-reviewed pediatric cardiology journal. Surveys provided the option for respondents to be identified if they wished to be acknowledged. All survey data was stored securely in a password protected document accessible only by the study team.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDemographics and descriptive statistics including Likert scale responses from the survey were summarized by medians with interquartile ranges and frequencies with percentages. Within the survey, participants ranked items which were then calculated by means with standard deviations. The open-ended prompts were manually coded by two independent reviewers which then were compiled into themes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eThe survey was distributed to chiefs in pediatric cardiology centers around the world. Demographics included the number of years in practice as a pediatric cardiologist, number of years serving as pediatric cardiology chief, and whether this was their first chief position (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In total, 31 chiefs representing 22 countries responded. Approximately 23% (7) of respondents were female.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant demographics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants %, (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProgram Location, % (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAustralia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDenmark\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHong Kong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIceland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIreland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNew Zealand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNorway\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRomania\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSlovakia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth Africa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSweden\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThailand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears in practice, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (18, 30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears served as chief, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3, 13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst time position, % (n)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiopulmonary bypass cases a year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e101\u0026ndash;250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e251\u0026ndash;400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e401\u0026ndash;600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e601\u0026ndash;800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e801\u0026ndash;1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepartment faculty size, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (7, 21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eKey Attributes of Effective Chiefs\u003c/h3\u003e\n\u003cp\u003eThe survey tasked participants to rank a list of traits in order of importance for the pediatric cardiology chief role (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In summary, the top 4 traits were similar in ranking to the North American pediatric cardiology chiefs in prioritizing communication skills, honesty, hard-working, and management skills. Interestingly, the data diversified in the global survey with a larger parity in ranking of traits after the top 5 compared to the North American chief responses aside from \u0026ldquo;Teacher\u0026rdquo; and \u0026ldquo;Reputation\u0026rdquo; also being ranked last.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAverage ranking of traits important for pediatric cardiology chief role (1\u0026thinsp;=\u0026thinsp;most important, 14\u0026thinsp;=\u0026thinsp;least important).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage Rank (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunication skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.9 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHonesty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHard-working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.5 (3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManagement skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquitable treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.5 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffective negotiator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.6 (3.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecisive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcademic excellence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePromoting psychological safety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.2 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.2 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConflict resolution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.4 (3.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHumility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.5 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVisionary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.5 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.8 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.5 (3.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eResponses pertaining to chief position longevity and succession.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eResponse, % (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDepends\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShould the chief position rotate every 5\u0026ndash;10 years? (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you believe succession planning is important as a part of the chief role? (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIf you started your career over, would you serve as chief again? (n\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo you think formal management education (i.e. MBA) is important to be effective in the role? (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59 (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen combining these rankings with open-ended responses there were clear categories which were organized amongst the global chief participants which were organized based on the various responsibilities and facets of a cardiology chief (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Specifically, the lists were also organized in descending order from the most commonly referenced items within each category.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eLikert Scale Responses\u003c/h3\u003e\n\u003cp\u003eSurvey items were rated on a 5-point scale which is summarized in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb. Respondents reported satisfaction in their tenure as chief. Compared to data from North American chiefs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], participants did not appreciate higher expectations from faculty and managing the department although they recognized higher pressure from patients/families and the corporate suite. Like the North American counterparts, there is a similar commentary of changes in work ethic amongst faculty and trainees which was cited as mainly due to more emphasis on work-life balance with several clarifications that this was not a bad thing. Finally, when tasked in responding about items pertaining to program expansion and program ranking, global respondents did not resonate with these items compared to North American counterparts and faced different challenges (i.e. staffing issues, different healthcare system models).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Prompts and Themes\u003c/h2\u003e \u003cp\u003eWe also included open-ended questions like our other survey design in determining the priorities, challenges, and benefits of serving in the role of a pediatric cardiology chief amongst a global audience. Two main themes emerged from the coded data which included: 1) Building and developing a well-functioning team is essential for long-term success of the program; 2) The role requires a strong sense of self and responsibility to others as well as oneself in terms of knowing one\u0026rsquo;s limitations and strengths.\u003c/p\u003e \u003cp\u003eThe first theme overwhelmingly was repeated by participants in terms of stressing the importance of teamwork, building a well-functioning team, and the challenges of managing a dysfunctional team which all contribute to the outcomes of a program. These include the responsibilities of the chief recruiting and hiring the right people as well as being responsible for developing faculty and the culture of a program well. It is also important that a recurring item with this theme also included the need to bring a team together in a single vision/mission.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...To establish a [program] where colleagues feel welcome and are devoted to aim for the highest clinical and scientific standards within pediatric cardiology\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;...Choose your best team. Realize who has the potential and how to achieve the best results as a team. Make everybody shine - see the potential in your employees, give them time and room to evolve\u0026hellip;\u0026ldquo;\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e...Keeping a big team happy and together is difficult! Be visible and approachable. Be kind\u0026hellip;\u003c/p\u003e \u003cp\u003e..Building a team is more important than excellence. A mixed team of both sexes is important. Different personalities are needed in different areas of cardiology\u0026hellip;\u003c/p\u003e \u003cp\u003e...Developing and sustaining a harmonious team is the most critical aspect of running a pediatric heart program\u0026hellip;all the members of the team should deeply resonate with the mission and vision of the program that needs to be articulated with great clarity\u0026hellip;\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe second theme resonated with much more introspective insights from respondents that emphasized elements that were not readily visible to their team members or patients. It became more apparent that the need to self-actualize is a crucial step in developing a leadership style and ability to lead.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...Be loyal to yourself and your team. Fight for what you think is the best for your team and the patients - even if [others] want you to do differently. Do not be afraid or hesitate to take an unpleasant decision if you know or think it is the right thing to do\u0026hellip;\u003c/p\u003e\u003cp\u003e...Leadership can only be sustained if the leader leads by example\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterestingly, while not as high of a frequency in responses to warrant a third theme, there were many comments surrounding the clinical competency and skills as a physician that respondents felt were important in being a successful chief:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e...The essential attributes would include high degree of clinical competence, excellent communication and teaching skills, a deep understanding of what it takes to be a good mentor, an excellent grasp on the healthcare landscape of the region\u0026hellip;it is also important to develop excellent working relationships with other providers\u0026hellip;\u003c/p\u003e\u003cp\u003e...be a very good doctor in pediatric cardiology, probably the best...be a good leader\u0026hellip;be capable of coordinating a team\u0026hellip; be an example for others\u0026hellip;\u003c/p\u003e\u003cp\u003e...I think the perfect chief needs professional insight broadly in pediatric cardiology as well as good leadership abilities\u0026hellip;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite the wide range of program sizes, models, and healthcare systems compared to the North American model [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], there were a lot of similarities when assessing key attributes for the pediatric cardiology chief role with the main crux revolving around communication and interpersonal skills (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a higher emphasis from the global counterparts on a leadership model emulating more similarly to a \u0026ldquo;role model\u0026rdquo; as opposed to a \u0026ldquo;servant leader\u0026rdquo; which was more common in North American programs, emphasizing the need for clinical expertise in the field. In fact, \u0026ldquo;servant leader\u0026rdquo; was seldom mentioned at all amongst global respondents outside of North American programs.\u003c/p\u003e \u003cp\u003eThere was an emphasis on the challenges and pressures of the chief position for program excellence which stemmed from the ability of a team to function at a high level. This is again dissimilar from the North American counterparts where they felt the push for program excellence was propagated by the need for program expansion. It is reassuring that ultimately respondents were very satisfied with the role regardless of nationality or program structure which again emphasizes that the role possesses more positive outcomes than detriments.\u003c/p\u003e \u003cp\u003eIn terms of succession planning, while there was near unanimous sentiment in its importance, there was less clarity in the need for term limits. When examining open-ended comments these responses were reinforced by the justification that excellent chiefs should be given the opportunity to serve longer than anticipated should the group agree to do so rather than be forced to turn the role constantly.\u003c/p\u003e \u003cp\u003eWhen examining how to best construct the \u0026ldquo;perfect\u0026rdquo; pediatric cardiology chief from the data provided there is a heavy emphasis on the chief\u0026rsquo;s ability to build and develop a team with strong interpersonal skills in addition to clinical excellence to lead by example. It should also be acknowledged that like prior studies, there is a continued lack of representation in leadership with respect to diversity, equity, and inclusion [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. While certainly those most fit for the role are the ones who take the position, there is invariably both conscious and unconscious biases influenced by culture (workplace and societal) and interpersonal dynamics that should be a consistent reminder increased sensitivity so that those in influential leadership positions, whether it is a pediatric cardiology chief or even editorial boards, are representative of the population and workforce at large [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince the Covid-19 pandemic, international collaboration and communication has risen dramatically which opens several new potential opportunities within pediatric cardiology. For a highly subspecialized field, shared information and practices can continue to advance the field and create dialogue which often may occur at the direction of the chief. Proper leadership education, training, and intentionality is important to build functioning partnerships globally [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe therefore have proposed several components for ongoing efforts on a global scale for pediatric cardiology programs and chiefs to address our findings:\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProposed Supports for Chiefs of Pediatric Cardiology Programs\u003c/span\u003e:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eGreater research on the role of the chief position globally including leadership training, education, and collaborative efforts\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIncreased support for women in leadership roles and sensitivity to diversity, equity, and inclusion efforts\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDevelopment of formal workshops to facilitate forums in which chiefs can share challenges with the role\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEstablishment of regular online meetings for chiefs to discuss challenges and successes\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInnovation in pediatric cardiology fellowship education with tracks for those interested in administration and leadership\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThere are several limitations that should be acknowledged in this study. This questionnaire, while reviewed by multiple cardiologists, is not a widely validated instrument as one does not currently exist [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. We expanded the voice of the chiefs in this study by expanding the scope of programs on a global scale \u0026ndash; we did not completely capture every country nor did we achieve a high number of respondents although we attempted to control the representation from certain regions due to the number of programs. While the perspective of the chiefs is highly valued in this research question, other stakeholders within the department are likely just as important (i.e. faculty).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe discovered the role of pediatric cardiology chief is widely variable on a global scale. There were enough differences highlighted to challenge the notion that while North American programs academically represent an archetype for clinical excellence, there is much to be gained and appreciated from a global perspective. Further studies can examine these similarities and differences at a deeper level whether that is direct comparison of different healthcare models, program structure, and center volume.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no relevant financial disclosures or conflicts of interest with the study. \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.K. and C.M. wrote the main manuscript of the text and prepared the figures/tables. All authors reviewed the manuscript and provided important feedback for the study.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe are grateful to Dr. Tara Bharucha, University Hospital Southampton, United Kingdom; Dr. Gianfranco Butera, Ospedale Bambino Ges\u0026ugrave; Roma, Italy; Dr. Giovanni Di Salvo, University Hospital of Padua, Italy; Dr. Gabriela Doros, Louis Turcanu Emergency Children\u0026rsquo;s Hospital, Timisoara, Romania; Dr. Ulrike Herberg, University Hospital RWTH Aachen, Germany; Dr. Lily Montalvan, Hospital Infantil Sabara, Brazil; Dr. Gylfi \u0026Oacute;skarsson, National University Hospital of Iceland, Iceland; Dr. Michael Rahbek Schmidt, Rigshospitalet, Copenhagen, Denmark; Dr. Juan Ignacio Zabala Arg\u0026uuml;elles, Hospital Materno Infantil de M\u0026aacute;laga, Spain; Dr. Martin Zahorec, Pediatric Cardiac Center, National Institute of Cardiovascular Diseases, Slovakia for their participation in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKim ME, Franklin W, Dubin AM et al (2024) What makes an effective chief of Pediatric Cardiology: insights from chiefs of North American pediatric programs. J Am Heart Association. ; pe036908\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLederer E (2018) Leadership as a division chief of nephrology. Adv Chronic Kidney Dis 25:480\u0026ndash;484\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTauben D (2017) Interview with David Tauben: University of Washington, chief of the division of pain medicine. Pain Manage 7:233\u0026ndash;238\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMedina-Walpole AM, Sachs GA, Hazzard WR (2020) Chief to chief: reflections on cultivating the next generation of geriatrics program leaders. Journal of the American Geriatrics Society. 2020; 68: 2759\u0026ndash;2763\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcMahon CJ, Sendžikaitė S, Jegatheeswaran A et al (2022) Managing uncertainty in decision-making of common congenital cardiac defects. Cardiol Young 32:1705\u0026ndash;1717\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRyan A, Duignan S, Kenny D, McMahon CJ (2018) Decision making in paediatric cardiology. Are we prone to heuristics, biases and traps? Pediatr Cardiol 39:160\u0026ndash;167\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuignan S, Ryan A, O'Keeffe D, Kenny D, McMahon CJ (2018) Prospective analysis of decision making during joint cardiology cardiothoracic conference in treatment of 107 consecutive children with congenital heart disease. Pediatric Cardiology. ; 39: 1330\u0026ndash;1338\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcMahon CJ, Hickey EJ, Nolke L, Penny DJ (2023) Organizational culture as a determinant of outcome in teams: implications for the pediatric cardiac specialist. Pediatr Cardiol 44:530\u0026ndash;539\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaddell AJ, Wong KK, Barker AP, Warren AE (2015) Trends in pediatric cardiology referrals, testing, and satisfaction at a Canadian tertiary centre. Can J Cardiol 31:95\u0026ndash;98\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorrison ML, McCrossan BA, Sands AJ, Craig B, Casey FA, Grant B (2016) Referrals to pediatric cardiology outpatients: continued evidence of increasing workload. Clin Pediatr 55:1346\u0026ndash;1349\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKutty S, Delaney JW, Latson LA, Danford DA (2013) Can we talk? Reflections on effective communication between imager and interventionalist in congenital heart disease. J Am Soc Echocardiogr 26:813\u0026ndash;827\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeil TP (2013) Health management education in Europe and in the United States: a comparative review and analysis. Health Serv Manage Res 26:76\u0026ndash;85\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMidttun L, Hagen TP (2006) The private-public mix of healthcare: evidence from a decentralised NHS country. Health Econ Policy Law 1:277\u0026ndash;298\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriedman AH (2019) Talent alone is not enough: lessons learned in a decade as chief. Curr Opin Cardiol 34:87\u0026ndash;93\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeadows AM, Skinner MM, Hazime AA, Day RG, Fore JA, Day CS (2023) Racial, ethnic, and sex diversity in academic medical leadership. JAMA Netw Open 6:e2335529\u0026ndash;e2335529\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYedidia MJ, Bickel J (2001) Why aren't there more women leaders in academic medicine? The views of clinical department chairs. Acad Med 76:453\u0026ndash;465\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCapers IVQ, Johnson A, Berlacher K, Douglas PS (2021) The urgent and ongoing need for diversity, inclusion, and equity in the cardiology workforce in the United States. J Am Heart Association 10:e018893\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzeoke OM, Williams J, Ogueri V, Hills BK (2023) The heart of the matter: a path to building diversity in pediatric cardiology. Pediatr Cardiol 45:1364\u0026ndash;1371\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan MS, Usman MS, Siddiqi TJ et al (2019) Women in leadership positions in academic cardiology: a study of program directors and division chiefs. J Women's Health 28:225\u0026ndash;232\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEshtehardi P, Bullock-Palmer RP, Bravo-Jaimes K et al (2022) Women leaders: transforming the culture in cardiology. Open Heart 9:e001967\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalasubramanian S, Pasquali SK, Cousino MK et al (2023) Representation of women and minority faculty and fellows in academic pediatric cardiology training programs. J Am Coll Cardiol 81:1181\u0026ndash;1188\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChowdhury D, Bansal N, Ansong A et al (2024) Mind the gap! Working toward gender equity in pediatric and congenital heart disease: present and future. J Am Heart Association 13:e032837\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDunne E, Zuhlke L, Kumar RK, Casey FA, Penny DJ, McMahon CJ (2022) Editorial board composition among pediatric cardiology journals: time to cast the net wider. JACC: Adv 1:100137\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatlow, A., Chan, M. K., Bohnen, J. D., Blumenthal, D. M., S\u0026aacute;nchez-Mendiola, M., de Camps Meschino, D., \u0026hellip; Busari, J. (2016). Collaborating internationally on physician leadership education: first steps. Leadership in health services, 29(3), 220\u0026ndash;230.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Congenital Heart Disease, Chief, Leadership, Pediatric Cardiology Program, Collaboration","lastPublishedDoi":"10.21203/rs.3.rs-6942966/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6942966/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eWhile the position of a pediatric cardiology chief is seen as the apex of one\u0026rsquo;s academic career, its roles, responsibilities, and qualifications are not well defined in literature. We previously surveyed North American pediatric cardiology chiefs to characterize these qualities. It is not known if these findings apply across programs around the world.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study was done to gain further insight of the role and attributes of a pediatric cardiology chief beyond North American programs by surveying those who are currently serving the position around the world.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis was a mixed-methods study that sent a survey out to pediatric cardiology chiefs from around the world. The survey was a semi-structured questionnaire independently reviewed by three cardiologists. The survey included items rated on a 5-point Likert scale, open-ended prompts, and targeted questions regarding the chief\u0026rsquo;s role and qualifications.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e31 pediatric cardiology chiefs from 22 countries completed the survey. The 4 most important traits for the role of chief included communication, honesty, work ethic, and management skills. 60\u0026ndash;75% of responses reported a change in faculty and trainee work ethic. 50\u0026ndash;60% of responses also reported increased expectations from patient families and hospital administration. Thematic analysis on the challenges and success of running a department revealed the importance of developing a team and needing a strong sense of self and responsibility for the team.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe gathered information directly from current pediatric cardiology chiefs from around the globe examining the current era of its role. Awareness of such key attributes may help promote effective leadership skills as chiefs of pediatric cardiology.\u003c/p\u003e","manuscriptTitle":"What Makes An Effective Chief of Pediatric Cardiology: Insights From Chiefs of Programs Globally","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 07:05:00","doi":"10.21203/rs.3.rs-6942966/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-08T04:05:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T18:06:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T15:19:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-05T20:40:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-05T03:04:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-04T05:21:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"186641213525818709590683506406294235103","date":"2025-07-03T04:24:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337451260281940078620722654532252703067","date":"2025-06-27T14:49:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182337445287455776977242249969772819213","date":"2025-06-27T10:34:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-26T22:17:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29582977932271274452144882449974905175","date":"2025-06-26T17:07:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"51580859450424931474910861824410528916","date":"2025-06-25T08:08:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332872560653737421263062532980147870180","date":"2025-06-25T02:59:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"232989868867326578564794576141460945223","date":"2025-06-25T02:55:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-25T02:44:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-24T12:41:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-24T12:40:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Cardiology","date":"2025-06-21T06:06:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-cardiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pedc","sideBox":"Learn more about [Pediatric Cardiology](http://link.springer.com/journal/246)","snPcode":"246","submissionUrl":"https://submission.nature.com/new-submission/246/3","title":"Pediatric Cardiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d3fd5eb1-5a85-4c8d-8db9-0365651e6b60","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-25T16:33:46+00:00","versionOfRecord":{"articleIdentity":"rs-6942966","link":"https://doi.org/10.1007/s00246-025-04002-4","journal":{"identity":"pediatric-cardiology","isVorOnly":false,"title":"Pediatric Cardiology"},"publishedOn":"2025-08-22 15:56:55","publishedOnDateReadable":"August 22nd, 2025"},"versionCreatedAt":"2025-07-02 07:05:00","video":"","vorDoi":"10.1007/s00246-025-04002-4","vorDoiUrl":"https://doi.org/10.1007/s00246-025-04002-4","workflowStages":[]},"version":"v1","identity":"rs-6942966","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6942966","identity":"rs-6942966","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}