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EDITORIAL |
Chicago, USA
It is well established that cardiovascular disease is the leading cause of death in the world, in developing countries as well as in developed countries. Public health authorities have recommended control of this problem by initiating traditional public health remedies, i.e., improved diet, cessation of smoking, treatment of hypertension and so on. These efforts, while admirable, do little to help those people who already have significant cardiovascular disease, and the long-term value of traditional public health measures requires dramatic changes in the culture, and in daily habits of large numbers of citizens. Even in developed countries, despite a daily barrage of public health messages, the conversion of the majority of people to the recommended lifestyle has not been very successful. The one element that has demonstrably improved mortality statistics in cardiovascular disease has been intervention, either surgically or by intravascular techniques.
The availability of resources personnel for these interventions, at least in the US, arises from the willingness of people in need to support the development and wide distribution of the necessary facilities and equipment, and to compensate the professionals for their skill and effort. The relationship between physician and patient is firmly cemented by the recognition that the physician is well trained and dedicated to the safety of the patient. This relationship is breaking down to some extent in the US for many reasons, but that would be the subject of another opinion piece.
A considerable premium in the US, and recently in Europe, is placed on the cardiovascular surgeon being certified as a specialist by a recognized training and examining body, in the US the American Board of Thoracic Surgery, and in Europe by the European Board of Cardiothoracic Surgery. This certification provides public affirmation that the physician has completed appropriate training and has been examined in the specialty. It is well recognized that this certification does not mean all certified surgeons are equivalent. However the patient knows, at the very least, that his surgeon has been trained and examined by respected members of the specialty.
Many humanitarian organizations have organized or sponsored cardiovascular surgical teams to go to developing countries to treat patients with heart and lung disease. The teams usually consist of professionals, including surgeons, anesthesiologists, nursing and other technical medical personnel. When they are visiting countries in need, the professionals also teach and train for the period of time they are at the site. While this is a valuable contribution, this kind of ad hoc training is not comparable to a structured, formal training program. There is no final examination, and no certification of accomplishment when the period of education is over. The mission of the humanitarian organizations is admirable, but it is not co-ordinated. Recently, the World Heart Foundation, founded and supported by Dr. Jim Cox, has brought some order to the various organizations participating in these efforts, beginning at the start to identify and catalog the interests of those groups engaged in this activity. Hopefully, it will be possible one day to co-ordinate these activities so that more efficient use of resources can be achieved. However we are all grateful that so many dedicated professionals are providing expertise and resources.
It is the opinion of many professionals that regardless of the good deeds provided to developing countries by visiting cardiovascular teams, those activities do not appear adequate for producing sustained quality services by the very nature of their temporary characteristic. In a statement from Sir MagdiYacoub, founder of the Chain of Hope Foundation (a group which has been very active in providing cardiothoracic services in developing countries), the needs for the future of cardiac services are described: "one of the main goals of the Chain of Hope is to help establish sustained quality cardiac services, including surgery, to communities where such services either do not exist or are poorly developed and to recognize the importance of the existence of potential suitable local candidates in these countries who can be trained to autonomously carry on with the envisaged services in the mid and long-term."
Although it is true that in many developing countries, well-trained and able professionals are available to provide cardiac care, that is not the case in all developing countries. Furthermore, many countries already have training programs, varying from well organized to rather informal. I believe it is fair to say that the completion of the national programs in most of these countries does not provide the successful candidate with the public acceptance of their skills as completely as is the case in the US or in Europe. The receipt of a national certificate seems to have gained little stature in the International Community.
In January of 2004 a meeting of a group of international authorities in cardiothoracic surgery education, training and certification was convened. At that meeting a proposal was introduced to begin the development of a process that would lead to an International Certificate in Cardiothoracic Surgery, a certificate intended to carry wide recognition for the integrity and quality of the program. If such a program could be developed, it would have many beneficial effects. First, and perhaps most importantly, it would give comfort to patients everywhere to know that their surgeon had undertaken and completed a process of training and examination designed by international experts in the field, and was certified as having met international standards. If a standardized process could be established, it could also provide for improved mobility for surgeons to work in countries outside their own country of residence. The importance of standardization, integrity and quality is critical. Any legitimate question of the integrity of the certification process will lead to a breakdown in the value of the certificate.
Recognition of professionals in developing countries by international authorities will do more than give deserved endorsement to a surgeon and the team, (although encouraging these dedicated people is very important). It surely would have a salutary effect on the possibility that patients who can afford to support the local team will do so; either by having their own medical care locally, or by donating to the local group to make available resources that might be helpful for their own future care. All of us are well aware that the most enthusiastic donors to hospitals in the US are people of means who have reached an age when they are most desirous of being certain that excellent medical care is available nearby.
This is an enormous undertaking, no doubt. There are recent developments that make it feasible. CTSNet has evolved in a remarkable fashion to become the portal for cardiothoracic surgeons worldwide, particularly for the continued education of these professionals. The availability of CTSNet makes it possible to offer worldwide a standardized curriculum, secure didactic examination (the in-service examination for all residents in cardiothoracic surgery in the US is being given today on CTSNet and has been given online for several years). It will even be possible to give oral examinations online using streaming video conferencing in a relatively inexpensive way. The availability of high speed Internet connections in developing countries is accelerating and will be wide spread in a short time. The tools are in place. The will and expertise to undertake this job has been demonstrated. The principal obstacle, as is so often the case, will be political, a frequent problem when changes are initiated. We must work together to sort out the needs and problems of all our colleagues, and their countries, recognizing the differences in communities for various medical services while adjusting for cultural differences. However, the core requirement for this process to be successful is to insist on integrity, quality and fairness in the process. It will require effort, but it is the right thing to do.
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