Opportunities for International Cardiac Surgical Training: Toward the Global Cardiac Surgery Resident

Global Variation in Training

Accreditation

Cardiac surgery training is subject to vast global variation in pathways and scope as reflected by differences in terminology (i.e., cardiac surgery, cardiovascular surgery, and cardiothoracic surgery). In many countries, cardiac surgical training follows after general surgery.(1,2) In Canada, the United Kingdom, Germany, and Brazil, for example, trainees enter integrated cardiac surgery residency programs from the start.(3) In the United States, a mixture of pathways exists (5+2, 4+3, and 0+6 years of general surgery and cardiac surgery). In some countries, such as Egypt, full licensing to become a cardiac surgeon can be obtained through medical masters degree in cardiothoracic surgery, which inherently is an academic degree with no specific clinical competency requirements and has only recently introduced a parallel pathway through a board exam. In general, global incompatibility between various training pathways, heterogeneous benchmarks for skill acquisition, and accreditation requirements introduce challenges such as “brain-drain,” duplicative training time and global resources spent on training when traveling abroad, and also unnecessary financial barriers for these trained surgeons seeking practice abroad.

Given such structural diversity across the globe and even within countries, it is no surprise that international accreditation and licensing is likely not foreseeable in the near future. Training challenges such as determination of competency, ideal trajectory of progression to independence, and facilitation of a productive yet safe learning culture are clear examples of universal concerns.

Technical Variation

While non-universal health coverage systems may implement more liberal resource utilization as cardiac surgical technology develops, LMICs emphasize cost-minimization, optimizing functional outcomes, and minimizing reintervention and longitudinal healthcare spending. Such factors impact management approaches, especially in LMICs. Examples of technical variability include repair-oriented strategy for rheumatic mitral valves, preference for off-pump techniques, and emphasizing autologous materials in LMICs. Rheumatic repairs aim to limit lifelong anticoagulation, complications, and re-interventions associated with valvular prosthesis, especially in the characteristically younger-presenting patients or those with tenuous follow-up or access to medications. While repair durability is highly reliant on careful patient selection (e.g., degree of valvular calcification), surgeons’ expertise, resource availability, and patients’ socioeconomic background (e.g., ability to afford anticoagulation or reintervention) greatly affect valve repair versus replacement strategies. Further, the use of treated autologous pericardium in place of synthetic patches, whenever possible, decreases material costs and the risk of endocarditis to the patient. However, human materials such as pericardium or homografts may be inaccessible due to cost or legal restrictions.

Lastly, minimally-invasive techniques remain centralized in high-income countries (HICs) where the cost barrier to entry is surmountable. The reduced risk of complications may render some minimally-invasive approaches more cost-effective in the long-term despite initial investment barriers, and can allow patients to return to home and work faster. Conversely, in resource-limited locations, the need for alternative techniques results in varying training profiles. Such technical variations and material availability clearly impact the exposure of trainees to management approaches and shape their decision-making in future practice.

Clinical Variation

Ischemic heart disease is the leading burden in HICs and rapidly rising in LMICs. Over 30 million people in LMICs live with rheumatic heart disease; in HICs, it is confined to immigrant, marginalized, and indigenous populations.(1,2,4,5) Endemic diseases such as endomyocardial fibrosis and Chagas cardiomyopathy are not uncommon in equatorial African countries and South America, respectively. Importantly, characteristically older, earlier-presenting HIC patients contrast with LMICs patients who are generally younger, more acutely unwell, and with more progressive disease, drastically impacting management.(1,2,4,5) Consequently, LMIC centers may adopt unique techniques tailored to “atypical” presentations. For example, the Aswan Heart Centre in Egypt achieved excellent results from their modified Mustard procedure technique for late-presenting children with transposition of the great arteries who have missed the window for conventional arterial switch repair.(4) Similarly, trainees in jurisdictions which preclude cardiac transplantation, where cultural beliefs limit the use of organ donors, or where adherance to long-term immunosuppressive therapy is unreliable, may not train in transplantation, instead emphasizing destination therapy ventricular assist devices and palliation strategies.

Training Preparedness

The degree of autonomy and preparedness for practice abroad is highly variable. Expectations of and by trainees must be framed by an understanding of these variations for successful international integration.(5) Cardiac surgeons with humanitarian surgical experience through bilateral partnerships reported being variably comfortable with performing valve repairs, likely due to its higher adoption in LMIC settings.(5) Countries where formal accreditation is based on academic rather than clinical criteria may emphasize the acquisition of clinical skills in later post-graduate fellowship years, and trainees may even be expected to travel abroad to acquire these skills prior to starting practice. Additionally, “global trainees” may have more cultural understanding and sensitivity to communities with different laws or beliefs, different attitudes/thresholds regarding palliation, or financial concerns of patients without financial risk protection.

Simulation Training

In this era of excellent cardiac surgical outcomes, simulation is a necessary component of training; however, models and consumables may be expensive and inaccessible to some programs.(6,7) This is especially the case for the more complex cases which are relatively more common in LMICs, such as progressive disease presentations or endemic pathologies. Video-based simulation has especially enhanced the ability for global training and feedback and may be supplemented with the introduction of low-cost, low-fidelity simulators, which may be scaled in LMICs. Moreover, integration of simulation-based training should be encouraged by accreditation bodies, societies, and local leadership. As some LMIC centers are currently or potentially high-volume, these regions represent an opportunity for industry investment.(6,7) Such strategies are particularly important to be leveraged in current times where travel is greatly restricted, and universally for trainees/mentors who do not have the means, ability, or interest to travel in-person.(7) Additionally, simulation training can be ensured along with supervision by faculty from any part of the world facilitating rigorous and specialized educational support.

Global Approach to Didactics

Throughout training, the teaching process includes internal didactics for programs’ own residents. Generally, this occurs through small groups of faculty and residents focusing on centralized and often region- and center-specific exposures, limiting the extent of the educational process and rendering it inefficient. With an increasingly virtual world, the “global cardiac surgery resident” may benefit from didactic processes including international faculty, speakers, and audiences to participate and share invaluable knowledge not attained at a single institution. Hence, residents are exposed to a global set of experts and connect more regularly with peers elsewhere across the country, region, or globe. Because only a fraction of cardiac surgical education revolves around the operating room, this demand for “global faculty” is a paralleling need in our process of evolving education into a teaching and didactic movement allowing expert knowledge to be taken further. In addition, this system may be implemented as a partnership between certain faculty and schools or as a visiting/traveling structured system that can strengthen academic collaborations and support capacity-building abroad.

As training pathways and practice approaches vary greatly between countries, regions, and even institutions within the same area, a streamlined, sustainable, and unified system-based practice approach may be fundamental. The “global cardiac surgery resident” sculpted within a global educational approach may prove more versatile in resource-considerate practice or in centralized state-of-the-art institutions due to global didactics. Cardiac surgeons working in peripheral centers for example, can offer brilliant contributions and knowledge to residents on the skillsets required and solutions to potential surgical disease presentations in remote locations.

Through continuous surgical education, whether in-person or virtual, surgeons in remote and lower-income regions may benefit from an international and centralized learning experience. This has been illustrated by the increasing participation of low- and middle-income country trainees and surgeons in virtual conferences, webinars, and workshops throughout the COVID-19 pandemic and should be sustained in hybrid formats beyond the pandemic.(7,9) Additionally, having proctors from more experienced metropolitan centers visiting and assisting in a variety of cases can improve local performance. Likewise, allowing these surgeons the opportunity to go and learn other procedures at these higher-volume or higher-resourced centers allows for a clear pathway towards continuous training. This strategy can help provide quality surgical education and encourage trainees and surgeons to remain in their home regions while optimizing their practice.

Relevance of International Training to Post-Training Practice

Of course, not all trainees will incorporate global cardiac surgery into eventual practice. However, in addition to universal and bidirectional advantages of incorporating training in variable-resource environments, such diverse training may motivate a greater number of trainees to integrate limited-resource practice either in part, in full, or in a remote/virtual fashion which may be highly beneficial to promoting local sustainability.(8) Because peripheral and remote centers often require cardiac surgeons to perform procedures outside their usual scope of expertise, such training experience likely encourages resourcefulness, creativity, detailed understanding of surgical pathology, mental preparedness, and more comfort with independent problem-solving.(8) These include but are not limited to general thoracic (pleural/lung) surgeries, abdominal aortic dissections in areas where general surgeons do not have the expertise or where there are no vascular surgeons available, thus requiring the cardiac surgeon to intervene and assist, and congenital heart surgery when adult cardiac surgeons do not have the necessary congenital expertise.(8) These skills are transferable regardless of eventual practice location and thus contribute to the overall development of the field worldwide.

In successful LMIC center models, such as the Aswan Heart Center, local surgeons were initially trained to perform only a narrow scope of simple procedures, strongly emphasizing perioperative management and triage skill training first. Establishing referral channels required significant efforts in developing critical partnerships with local generalist partners throughout the country and continent. This was performed with strong remote support from international mentors. While global residents may have a greater interest or need to be well-versed in these issues, any new cardiac surgeon entering into practice would benefit from such exposure and system-wide thinking. Health disparities persist in HICs as do challenges in avoiding late or entirely missed referrals for cardiac surgical consideration/intervention.

There are currently no official “global cardiac surgery training” programs. Despite increasing awareness and interest in the concept of “global cardiac surgery,” practical efforts toward this effort remain in their infancy. By shifting the discussion towards establishing concrete strategies, we can hope to achieve concrete, sustainable, academic partnerships with mutual benefit.

Opportunities for the “Global Cardiac Surgery Resident”

As we become more acquainted with the specific needs, nuances, opportunities, and assets of each cardiac surgical population and practice, we propose the following practical means of advancing and expanding global cardiac surgical opportunities in the modern era including precedent examples where applicable:

• Accredited international electives with defined structure:

• Programs should recognize international electives, not only allowing them during time off clinical duties.

• Societies should offer greater funding support and formal accreditation of international experiences, especially for LMIC trainees who lack access to conferences, awards, and funding.

• Residency programs could assist with financial support or link trainees with available opportunities.

• Longitudinal partnerships:

• Long-term partnerships with centers should be encouraged with repeated visits as trust needs to be built over time before an international resident can reasonably expect to partake actively in patient care abroad. Various academic programs (e.g., the University of Toronto in Canada as well as the Addis Ababa University in Ethiopia) and non-governmental organizations (e.g., Team Heart and the King Faisal Hospital in Kigali, Rwanda) have developed various long-term collaborations ensuring continuity, expansive capacity-building, and mutual learning whereby trainees from both sides may engage with each other.

• International elective time should be optimized to ensure hands-on surgical skill training objectives are met, as these can be challenging in international settings before long-term partnerships are established.

• Site selection should consider partnering centers’ complementary surgical skills, services, and training needs.

• Extended international residency training curricula:

• In the United States, Baylor College of Medicine has developed a “Global Surgery Residency” program as a first-of-its-kind by which general surgery trainees have two years of general surgery training recognized in LMIC centers. Similar developments may occur among cardiac surgery training programs, either in LMICs or HICs.

• Global surgery research fellowships:

• Programs such as the National Institutes of Health Fogarty Fellowship or the Paul Farmer Global Surgery Fellowship at Harvard Medical School may provide trainees with unique global surgical experience to become well-versed in all layers of budding and growing health systems.

• Simu-live training:

• Networks should be established whereby centers with local expertise can lead virtual workshops using didactic or low/high-fidelity simulation-based teaching which trainees can follow and replicate, even with low operative volumes. Expert instructors from rotating locations can provide feedback in real-time or through submitted footage of simulated practice.

• Global consult rounds or live on-call support:

• Networks should be established to allow low-volume centers to present challenging cases for advice or real-time support from partnering institutions.

• Leadership for logistical development/implementation could be facilitated by mutual global cardiac surgery residents.

• Defined clinical and technical competency milestones:

• There should be continued efforts to characterize common and unique competency requirements among diverse centers.

• Development of “common cardiac competencies” universal to cardiac surgery on a global scale may improve local surgical outcomes in the post-training period, more easily facilitate international travel for training, and avoid duplicative spending on training when milestones are not reached.

• Surgical competency is an expanding area and an opportunity for trainees to contribute leadership in global surgery from an ideal vantage point.

Students, residents, and young surgeons can get involved with programs already taking part in global cardiac surgery initiatives in anticipation of more established such training pathways. For example, through social media, there is a strong and growing global network of trainees who share their experiences, grow their networks, engage in international research collaborations, and lay the groundwork for future international educational opportunities.(10)

Conclusion

Globally coordinated and collaborative education is an essential component of ensuring worldwide sustainability and quality improvement in cardiac centers. In-person or virtual international training programs can promote continued development in our specialty globally in terms of disease understanding. Inherent to this is the establishment and solidification of partnerships between centers with mutual benefit and the development of globally-minded, forward-thinking next generations of surgeons. 

References

1. Vervoort D, Swain JD, Pezzella AT, Kpodonu J. Cardiac Surgery in Low- and Middle-Income Countries: A State-of-the-Art Review. Ann Thorac Surg. In Press.

2. Vinck EE. Cardiac surgery in Colombia: History, advances, and current perceptions of training. J Thorac Cardiovasc Surg. 2020 Jun;159(6):2347–52.

3. Nissen AP, Smith JA, Schmitto JD, Mariani S, Almeida RMS, Afoke J, et al. Global perspectives on cardiothoracic, cardiovascular, and cardiac surgical training. J Thorac Cardiovasc Surg [Internet]. 2020 Jan 28; Available from: http://dx.doi.org/10.1016/j.jtcvs.2019.12.111

4. Hosny H, Sedky Y, Romeih S, Simry W, Afifi A, Elsawy A, et al. Revival and modification of the Mustard operation. J Thorac Cardiovasc Surg [Internet]. 2019 Mar 22; Available from: http://dx.doi.org/10.1016/j.jtcvs.2019.03.027

5. Tamirat S, Mazine A, Stevens L-M, Agwar F, Dejene K, Bedru M, et al. Contemporary outcomes of aortic and mitral valve surgery for rheumatic heart disease in sub-Saharan Africa. J Thorac Cardiovasc Surg [Internet]. 2020 Apr 25; Available from: http://www.sciencedirect.com/science/article/pii/S002252232030996X

6. Vervoort D, Nguyen DH, Nguyen TC. When Culture Dictates Practice: Adoption of Minimally Invasive Mitral Valve Surgery. Innovations . 2020 Aug 26;1556984520948644.

7. Vervoort D, Dearani JA, Starnes VA, Thourani VH, Nguyen TC. Brave New World: Virtual Conferencing and Surgical Education in the COVID-19 Era. J Thorac Cardiovasc Surg [Internet]. 2020 Aug; Available from: https://linkinghub.elsevier.com/retrieve/pii/S0022522320322686

8. Vinck EE, Ebels T, Hittinger R, Peterson TF. Cardiothoracic Surgery in the Caribbean. Braz J Cardiovasc Surg. 2021 Feb 1. doi: 10.21470/1678-9741-2020-0377. Epub ahead of print. PMID: 33577262

9. Smood B, Spratt JR, Mehaffey JH, Luc JG, Vinck EE, Lehtinen ML, Wallen TJ, Jenkinson CG, Kim W, Kesieme EB, Han JJ. COVID‐19 and cardiothoracic surgery: Effects on training and workforce utilization in a global pandemic. Journal of Cardiac Surgery. 2021 Jun 25.

10.  Alejandra Castro-Varela, Jessica G Y Luc, Dominique Vervoort, Social media and global cardiovascular disparities, European Heart Journal - Digital Health, Volume 2, Issue 1, March 2021, Pages 3–4, https://doi.org/10.1093/ehjdh/ztaa019

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