International Cardiac Surgery:
A Global Perspective
A Thomas Pezzella M.D.
Seminars in Thoracic and CV Surgery 2002; 14:298-320
If I can stop one heart from breaking,
Lespwa fe viv- Hope makes us live
The big bang theory, as proposed by Stephen Hawkins, postulates that the universe and time itself came into existence at the same time around 13 billion years ago. In fact, this time span was only a fraction of a second (2). The planet earth had its origin approximately 4.5 billion years ago. Yet it wasn’t until 1543 AD that Nicolas Copernicus placed the sun and not the earth as the center of the Solar System.
Man appeared around 2.5 million years ago, the origin of which Thomas Henry Huxley called the question of questions. The exponential growth in human population reached 6 billion people on October 12, 1999 with a present annual rate of growth of over 70 million (3). By 2020 the population will reach 7.5 billion and by 2050, 9.3 billion (4) . This comes about even with a declining birth rate from 2.2% in 1963 to 1.3% in 1999. Only the Vatican has a 0% birth rate. The population growth is concentrated in South Asia (particularly India) and Africa. Our world population lives in over 200 countries and territories in the world (189 in the UN). Interestingly, the population lives on half the planet since the rest is covered with water (total global land area is over 400,000 square miles)(4). The average global life expectancy is 66.5 and ranges from 49 years in Sub Saharan Africa to 78 years in Western Europe (5). The global mortality is over 55 million deaths per year with infant mortality ranging from 6 per 1000 live births in Western Europe to 92 per 1000 live births in Sub Saharan Africa (4). Over 7.7 million children die worldwide before their first birthday(5). Despite this, the annual death rates are falling, clearly the result of improved nutrition, immunization, and infrastructure. The 1999 World health Organization (WHO) global mortality statistics are summarized in (Figure 1). Interestingly, deaths from non-communicable diseases or chronic disease are greater than from communicable disease. Also, of note, is the fact that the rate of growth of chronic disease in developing countries is rising. The Global Burden of Disease study by Murray and Lopez in 1997 (6,7,8,9) was a significant attempt to look at worldwide mortality and disability (DALYs). It was a joint study, started in 1992, by the WHO, the World Bank, and the Harvard School of Public Health. Estimates of incidence, prevalence, mortality, and DALYs, in 1990 for over 100 diseases/injuries and 10 risk factors were made and projected to 2020. The burden of mortality depicted in figure 2, shows 47.3% of the deaths in the developing countries are from non-communicable diseases. The overall DALYs in developing countries are projected to increase from 36% to 57% (figure 3) (10). It is estimated that by 2020 cardiovascular disease (CVD) will claim 25 million deaths per year with coronary heart disease as the number one cause of death and disabilities. This disability factor is of increased concern. This is the burden of disease. It is measured in terms of disability-adjusted life years (DALYs). [To calculate DALYs add the loss of healthy years of life and premature loss of life, and weigh it against the risk of dying at a certain age combined with the burden of illness over a lifetime or the sum of life years lost due to premature mortality and years lived with disability adjusted for severity.] (10)
Against this background of population, mortality, and disability emerges the global problem or challenge of trying to alleviate, resolve, palliate, cure, or eliminate the causes or factors that spawn it, spread it, and sustain it.
Table 1. Global Mortality, 1999
|Adapted from: World Health Organization: The World Health Report 2000, Annex Table 3.|
Whether we like it or not globalization is a reality and here to stay. Dwindling natural resources (especially fossil fuels), changing borders, emerging new countries (projected to increase from 200 to 250 over the next 30-40 years), the Internet, high-speed transportation, and increasing interdependence have forced us to change, share, transform, or revise our way of thinking and acting on this world stage. If viewed from just an economic and environmental point of review there should and will be increased global awareness and participation of people and countries on this planet. The global domestic product (GDP) is $30.9 trillion. More than $1.5 trillion is traded internationally each day with over 20% of the world production of goods and services being traded. Clearly, global economics is dependent on this world trade and production. Natural and man-made disasters have created geographic and environmental changes, especially with the increased number of refugees and the swelling of urban populations. The inescapable fact is we cannot ignore or run away from the phenomenon of globalization.
Table 2. Burden of Disease (1990 estimates) for the Three Economic Regions of the World
|% of Deaths in region due to:|
|Population in Millions
% Total World Population
*Includes cancer, diabetes. neuropsychiatric conditions. congenital
anomalies, and respiratory. dices ,‘e. genitourinary, and musculoshetal
EstME: Established marker economies—United States, Canada. Western Europe. Japan, Australia, and New Zealand.
•ErngME: Emerging marker economies—former socialist states of Russian Federation.
tDevE: Developing market economics~—China. India, other Asia and islands, Suh-Saharan Africa. Middle Eastern Crescent, Latin American, and the Caribbean.
Adapted from Murray CLJ. Lopez AD: The Global of Burden of Disease. Cambridge, MA, Harvard School of Public Health, 1996.
Table 3. Current and Projected Burden of Chronic and Infectious Diseases and Injuries in Selected Countries and Regions5
|County or Region||1990||2020|
|All developing countries|
Another way of looking at this objectively is the E-9, which is a collection of the larger developed and developing countries (Figure 4) (11). They represent both geographic and economic diversity. Clearly there is economic disparity. Pertinent to our discussion, representative health care cost and disease are depicted in Figure 5. Despite the high amount of expenditure in the USA, quality of care in the USA remains 37th in the world according to the WHO.
|Table 4. A Population and Economic|
|Country or Grouping||Population
Data for European Union do not include Luxemburg.
SOURCE: World Bank, World Development Indicators 2000 (Washington, DC: 2000), 10-12; Population Reference Bureau, "2000 World Population Data Sheet," wall chart (Washington, DC: June 2000).
The whole concept of globalization or interdependence is not a new one. Thomas L. Friedman (12) in his outstanding book "The Lexus and the Olive Tree", divides globalization into 3 eras: The pre World War I era was marked by intense migration of people to other countries, particularly America, and improved transportation and communication. The second era from World War I, the Russian Revolution, the Great depression, World War II, and through the Cold War saw no great international movement aside from almost total global destruction. The third era followed the breakdown of the Soviet System. Rapid and massive transportation, along with technology now gives everyone a chance to be involved in the global marketplace.
Simply put, globalization is the increasing interdependence that is emerging amongst the people and places of the world. No longer can we live in isolation from one another. Eventually, the impact of war, terrorism, natural disasters, financial ruin, climatic catastrophies, and disease will affect all of us in a major or minor way.
Once we appreciate the magnitude of the global problem we should focus on that area which demands or commands our interest, knowledge, expertise, and participation, namely medical care. Domestic health issues still concern all of us. The changes in health care in the United States have been well outlined by Jerome P. Kassirer (13). Needless to say market forces alone will not solve the rising costs of medicine, and access to care, especially with the roles of uninsured and underinsured patients in the USA rising to over 44 million. This has occurred in the face of an annual USA healthcare bill of 1 trillion dollars or 14-15% of GDP and the greater than $4,000 per person per year health care expenditure. Yet, Kassier in a further analysis of the physician’s role optimistically outlines a contemporary code of conduct (13) :
" We must declare that we are concerned foremost with the preservation of health and the care of the sick and that we will continue to base our clinical judgments on our evolving body of highly specialized, scientifically based knowledge, not on personal expediency or political motives".
" We must declare that we have intentionally set our ideals and ethical standards high, and that these ethical standards lead us to act in ways that are not self-serving".
Table 6. Four Current Challenges To Improve World Health
|*( 15) (with permission: Merson, M. H., Black, R. E., Mills, A.J. ed. International Public Heaith, Aspen Publishers, Gaithersburg, Nfarylar~d, 2001, p xxv)|
We must be far more responsible for the use of resources than we have been in the past. We should pay attention to the cost of car even when it does not come out of our wallets. We should learn the techniques of disease management and practice them if they both improved car and cost less. We should use less expensive drugs when they are just as good. We should take the time to discuss choices with patients and families when aggressive car is not the only option. We should stop over treating patients in our intensive care units to preserve a few more days of life of questionable quality".
"We must be sure that our own house is in order. Financial inducements are all around us. We should not be fooled into thinking that we cannot be influenced by the largesse of pharmaceutical companies and device manufacturers. Getting co-opted by industry in increasingly frequent and can have a pernicious influence on even the most senior clinicians and investigators".
"More individuals must get involved in both practical and ethical issues in local and national associations. We need more volunteers to join the well-intentioned and ethical organizations that are trying to make a difference, but they must be principled people who will avoid the herd mentality. We need individuals who are willing to put in the time, rise to the top, and make their views heard. It is the only way to avoid the kinds of embarrassments, scandals, and gross mistakes that have occurred in state and national medical societies over the past few years".
"Despite the recent National Labor Relations Board ruling, we should not be seduced into joining unions. Unions are designed to deal with the economic and social problems of their members, not professional issues. Some of our national medical organizations already behave like unions, and when they do, their opinions and policies are often discounted".
" We must always be agents for beneficence. We must speak out against profiteering by the burgeoning medical industry and argue vociferously for continued support for teaching and research". Given these facts, it is hard and sometimes difficult to gather support and attention for "non-domestic" issues.
To this stark realism I can only add a quote from Amram J. Cohen (14), a dedicated Israeli Cardiac Surgeon, who died tragically this past year: " I am convinced that for the vast majority of people who chose cardiothoracic surgery as a profession, idealism was initially a strong factor. For those of you who are reading this and just starting out, hold fast to our ‘day after-vision’ because, if it fades, despite all the skills acquired, there will be something missing. For those who are searching, join us and together let us make the network to help children with heart disease globally big enough to be equal to the task. There is work for everybody. There are no dollars and cents in it, but it is worth a fortune".
This brief background is a sobering reminder of the challenges facing our domestic medical profession. Figure 6 summarizes the challenges for the rest of the world (15) . Herein lies the problem and challenge of the next 50 years for cardiac surgeons i.e. providing access to cardiac surgery for more patients both at home or abroad recognizing the economic, political, social, cultural, and geographic constraints. Yet we must remain cognizant of our role in prevention and the fact that curative medicine still remains more expensive than prevention medicine. The Ghana model illustrates the mismatch of cost versus population served. (Figure 7)(16) However, the preventive medicine philosophy of dealing with initial control of infrastructure, vector control, vaccination programs, family health and planning, then progressive curative measures doesn’t totally suffice in the "modern medical battlefield"(Figure 8) (17). Internationally, there is more of a tendency to develop centers of excellence dealing with specific diseased systems. A longitudinal focused product line is very effective, i.e. a team composed of preventive and curative personal
Table 7. Some Differences Between Public Health and Medicine’
Primary focus on population
Primary locus on individual
Public service ethic, tempered by concerns awareness for the individual
Personal Service ethic, conditioned by Social responsibilities
Emphasis on health pronunciation and disease
Emphasis on diagnosis and treatment; care for the whole patient
Reliance on many sectors outside health care system
Reliance on health care system
working together to eradicate or control a particular problem. As an example, approaching rheumatic fever and heart disease involves a prevalence study, followed by documentation of the incidence, number of people with the problem, appropriate further evaluation and, finally, definitive care. Smaller, focused groups providing a holistic simultaneous approach to the problem or situation will replace the model of doing things in waves or stages. In fact, present day models testify to the fact that the product line approach is practical and is working. Examples include the emerging heart centers in China, India, and Vietnam. Fu Wai Hospital in Beijing, China performs over 5,000 open-heart operations/year. Escort Hospital in Delhi India averages 3,000 – 4,000 open-heart procedures / year, and L’Institute du Coeur, in Ho Chi Minh City, Vietnam performs over 1,000 open-heart procedures/ year. These centers are designed primarily to address the product line of cardiac disease. They are well staffed, focused, and effective, both patient care wise, and economically.
Global Trends in Cardiac Surgery
The modern era of cardiac surgery began with the successful closure of an atrial septal defect utilizing cardiopulmonary bypass, by John Gibbon in May 1953 (18). Over the past 50 years the growth in the quantity and quality of cardiac surgery has been nothing short of dramatic.
|Table 8. Estimated Global Cardiac Surgery|
|Open Heart Centers > 4,000|
|Cardiothoracic Surgeons > 6,000|
|Open Heart Annual Caseload 2-2.5 million|
|93%—No access to Cardiac Surgery (outside North America, Europe, and Australia)|
|North America 1222/million||1/120,000|
|Australia 780/million||I/I million|
|Europe 369/million||I/I million|
|South American 147/million|
|Asia 25/million||1/16 million|
|Africa 18/million||1/33 million|
|Adapted from references IS, 43, 44..|
Cox (19) estimated that 2-2.5 million open-heart operations by over 6,000 cardiac surgeons in more than 4,000 centers are performed annually on the planet (19). He stressed the gross global mismatch in terms of access to cardiac surgery and population served and outlined nicely the dichotomy of the haves and the have-nots (Figure 9). The global surgical manpower issue is clearly a problem of maldistribution (Figure 10) (20). Additionally, this distribution does not take into account the individual country milieu, in terms of the interaction of supply and demand.
Table 9. Number of Surgeons per
|Germ any||13||New Zealand||12|
|Latin America (Colombia)||7||United Kingdom||6|
|Kenya||.6||West African states||.5|
Recognizing the need for increased awareness of the global village Robert Replogle, as president of the STS, traveled the world in 1995-1996 gathering support of the major CT surgical societies to combine their efforts and share their concerns (21). These included a worldwide database, a shared curriculum for CT surgery training and education, as well as research efforts, and sharing knowledge and techniques (22). The Internet became a powerful tool to facilitate and energize this effort. Along with doctors Thomas Ferguson, Gerald Rainer, and Peter Greene, they pioneered and expanded the scope and dimensions of the CTS net. Today the CTS net is the most powerful force in CT Surgery in terms of the transfer of thoughts, ideas, information, skills, and technology. Our European colleagues have also joined in this universal effort to expand the knowledge base and deliver information. Paul Sergeant (23) has outlined nicely the role of the CTS net as a tool for the customer or member. Using the information from the CTS net creates a reengineering tool that helps improves performance, customer satisfaction and reduces costs. Bruce Keogh (24) introduced the spoke and wheel concept with local or regional groups and societies functioning off the CTS net. Cho and Tamru (25) vividly point out that the CT Surgeons of Asia, representing over half the world population, now have increased access to current knowledge and information. James Cox (19) has proposed an ambitious encyclopedia of cardiothoracic surgery available on the CTSNet.
Will the CTS net now replace journals, textbooks, and medical meetings? The simple answer is no. The complex answer is to some degree. Journals and texts are available online, and now can be downloaded in hand held PADs. They will now complement the journal or text and be readily available. Medical meetings will remain important and necessary. Virtual meetings and video telemedicine conferences will not replace or substitute for the human touch. E. Baudt (26) emphasizes the importance of colleagues meeting and interacting, as well as experiencing new cultures and places.
Many long lasting relationships have their foundation at these meetings. The controversy remains regarding the number and content of many of these meetings. The expenses are rising, and it is difficult to attend more than one or two per year for the average cardiac surgeon. Corporate support or sponsorship for attendance to meetings is also wavering. Yet, as Baker (27) explains, meetings afford the opportunity to share knowledge, establish, review, or sustain friendships, recruit faculty or residents/fellows, meet our mentors, and gain insight into our peers. On an international level the dominant CT surgery meetings in terms of attendance alone include the (AATS, STS, EACTS, and ASCVS). The proliferation of other specialized meetings and workshops have as their focus the goal of spreading new technology and techniques. These are extremely valuable and readily applicable to clinical practice.
The proliferation of major cardiothoracic textbooks, monographs dedicated to specific subjects, and cardiothoracic journals, have increased the depth of knowledge and information available. English has become the dominant language of medicine. On a global scale this creates more challenges. Articles from non-USA countries continue to rise in USA journals. In a comparison of 5 USA general surgery journals [American Journal of Surgery; Annals of Surgery; Archives of Surgery; Surgery; and the Journal of the American College of Surgeons (Formerly Surgery, Gynecology, and Obstetrics)] from 1983 to 1998 there was an overall decrease of 15.1% in USA articles. In 1998 66.8% of the articles were from North America, 17% from Europe, and 12.6% from Asia (28). The Annals of Thoracic Surgery reported 61% of manuscripts received in 2000 were from abroad (29). With this has brought the challenge of writing in a second language-English. Benfield (30) points out that of the languages used in medical publications cited in Medline in 1996, 88.6% were in English. Many foreign manuscripts need major revisions. This has added to the time delay in submission, acceptance, and publication. Edmunds (31) offers the concept of language editing. This involves deciphering the author’s intent and then translating it into "standard written" or "easily understandable" English. It is clear that English is and will expand as the common language of Cardiac Surgery.
In 1957 the communication age emerged with the launching of the Sputnik satellite into space. At the present time not only do we communicate globally but we and everyone else has the potential to know where we are and where we are going (advances in the global positioning systems (GPS) utilizing the 4 satellite navigation system have created that capability). Telecommunication has emerged as a powerful tool to transmit visual information. International cooperation began in 1971 with the Intelsat IV (International Telecommunications Satellite Organization) (32) .
Telemedicine is slowly but progressively making an impact in the areas of education and patient care. Already video conferences bring live operations into the conference rooms at distant sites. Real time consultations have become particularly valuable and popular. As the uplink costs decrease, this technology will become even more available.
Most programs in the United States are interactive video clinical consultations or the store-and-forward exchange of static images (33). The U.S. Army has one of the most active and experienced systems. The Telemedicine Directorate at North Atlantic Regional Medical Command (NARMC) based at Walter Reed Army Medical Center (WRAMC) has been functional since 1993. Clinical consultations have been their major focus with over 240 clinical consultations performed over the two-year period, 1993-1994.
www.wramc.amedd.army.mil. For cardiac surgery, tele-education, tele-mentoring, tele-presence surgery, and robotics are exciting modalities that will continue to enhance this global expansion. (34,35,36)
Figure 10. Four typical stages of the epidemiological transition
OF DEATHS DUE TO CVD (%)
|Types of CVD|
|Pestilence and famine||Predominance of malnutrition and infectious disease as causes of death high rates of infant and child mortality; low mean life expectancy||<10||Rheumatic heart disease cardiomyopathies is due to infection and malnutrition.|
|Receding pandemics||Improvements in nutrition and public health lead to decrease in rates of deaths due to malnutrition and infection; precipitous decline in infant and child mortality rates||10-35||rheumatic valvular disease, hypertension, CHD, stroke|
|Degenerative and Man-made diseases||increased fat and caloric intake and decreased physical activity lead to the emergence of hypertension and athero-sclerosis; with increased life expectancy, mortality from chronic, non communicable diseases exceeds mortality for malnutrition and infectious diseases.||35-65||CHD, stroke|
|Delayed degenerative diseases||cardiovascular diseases and cancer are the major causes of morbidity and mortality; better treatment and prevention efforts help avoid deaths among those with disease and the late promary events. age-adjusted CVD mortality declines; CVD affecting older and older individuals.||50||CHD, stroke, congestive heart failure.|
Our Cardiology colleagues have also become increasingly interested and involved in global activity particularly at the strategy and information level. Eugene Braunwald’s text of Heart Disease begins with a provocative chapter by Gaziano on the global burden of cardiovascular disease. He gives a comprehensive review of the epidemiological transitions (Figure 11). It is frightening to think that the 25% of predicted mortality for CVD in 2020 could actually be considerably higher as the world population moves closer to degenerative and delayed degenerative disease. Janus et al (37) in 1996 emphasized the increasing incidence of ischemic heart disease in Asia. Bayès de Luna in 1999 (38) announced the formation of the World Heart Federation (WHF). The primary goal of WHF is to promote joint projects with the WHO, and other foundations that emphasize prevention and decreasing cardiovascular disease in developing countries. Douglas Zipes (39) in his presidential address to the American College of Cardiology in March of 2002 emphasized the need to expand our vision to include "humankind". This included the development of ACCardio, an internet-based learning management system. This will parallel the CTS net as a vehicle to transmit knowledge and information.
The development of databases in the United States and Europe has greatly facilitated the documentation of the quantity and quality of cardiac surgical procedures. The STS database was established in 1994 and the EACTS database (ECSUR) in 1996(40,41). These have become the basis for severity scoring and risk stratification. Recently the ECSUR has expanded to develop on international surgical registry. Wyse (42) reports that through February, 1999,68 countries, which includes 1352 cardiac units, and 3951 surgeons, are involved in the database network.
Table 11. 1991 Snow Bird, Utah Retreat46
Felix Unger (43,44) has made a valuable contribution in expanding the European database to the international level. Under his direction, the Institute for Cardiac Surgery-European Registry was established in 1990 and transformed into the European Heart Institute in 1995. From 1995, the goal was to collect data on cardiac interventions and reflect on changing patterns. The data would serve as an objective means of planning and allocating financial resources. The future will include a combined STS/ ECSUR joint database committee to cover adult cardiac surgery, pediatric cardiac surgery and thoracic surgery. It is extremely important that the international databases seek quantity first, i.e. documentation of the number and types of cases. Many emerging centers may hesitate to record their early results. This is a sensitive area that must be appreciated and addressed. They clearly should not be penalized early in their development.
Surgical Training/ Education
Prior to World War II advanced surgical training was acquired in Europe. As an example, from 1870 to 1914, over15,000 USA under-graduate and post-graduate students studied in German medical schools alone(45) . In the early 1900’s William Halsted established the American Surgical Training System at John Hopkins Hospital in Baltimore. Following World War II American medicine advanced quickly in the United States. The American Board of Thoracic Surgery was established in 1948. Even prior to that, in 1928, John Alexander established a formal thoracic surgery-training program at the University of Michigan (46). Over the past 30 years the Western European programs have advanced at an amazing rate.
At the present time a major restructuring of the American training programs in cardiothoracic Surgery is evolving(47). In 1991, 50 thoracic surgery leaders made a series of recommendations regarding programs (Figure 12) (46) . In 1994, the Thoracic Surgery Directors Association (TSDA) published a comprehensive thoracic surgery curriculum. This contained 14 study units. Each unit contained the objective, the learner objective, content, and clinical skills (46) firstname.lastname@example.org. William Baumgartner (48) has nicely summarized the 10 recommendations of the ABTS to the Residency Review Committee in October 2001 (41). The essential changes included: ABS certification is no longer required; 3 pathways are allowed – 5 years general surgery with or without ABS certification plus 2-3 years thoracic residency; ABTS certification in an integrated 6 year program; or 3 years general surgery plus 3 years thoracic surgery. This whole process will require 1-2 years to formally adopt. The entire subject regarding the TSDA retreat of 2000 has been nicely summarized by Olinger (49) . Changes are clearly necessary in order to continue to attract interested and qualified candidates for a career in CT surgery. In the USA, a decrease or leveling off of cardiac surgery caseloads along with decreased reimbursement has had a negative effect on attracting residents. In fact, more and more established CT surgeons are seeking cardiac retirement. The Royal College of Physicians and Surgeons of Canada adopted a revised training program in 1997 (50). The overall period has been reduced to 6 years. It is imperative that a model be developed that can be readily adapted and monitored by the global cardiac surgery community.
Historically, there has been a long legacy of foreign medical graduates (FMG’s) receiving graduate medical education in the USA in both approved and non-approved residency or fellowship programs. 23% of active physicians in the United States are FMG’s (51,52) (Figure 13).
Table 12. Graduates of US and Foreign Medical Schools
Allopathic Physicians in the United States *31’52
|No. of Physicians|
|Graduates of US medical schools||398,430||437,165||483,039|
|Graduates of foreign medical schools||112,660||122,823||149,082|
*Data, which arc year-end numbers, are from the
American Medical Associations Physician \laster6le.
Approximately 10% of approved residency programs, i.e. accredited by the Accreditation Council for Graduate medical Education (ACGME) are filled by FMG’s (Figure 14) (51,52) . An unknown number have received specialized training in so-called non-approved programs. At present, the requirement for a JI visa to study in an approved program includes the ECFMG parts 1,2; TOEFL; and the Clinical Skills Assessment (CSA) (Appendix One) (53,54,55,56) . Recently, Richard Jonas (57) , highlighted the problems with the new JI visa limitations for FMG’s seeking specialty training in the USA in both approved and unapproved programs. This will have a profound effect on both the USA based programs and the foreign countries seeking advanced training for their physicians.
In 1951, the AATS established the Evarts Graham Memorial Traveling Fellowship (58). This allowed a non-North American CT Surgery fellow to spend one year traveling to various centers in North American to gain exposure to a variety of surgeons, programs, and technical procedures. On completion, they returned home to apply their experience.
|Table 13. Graduates of US and Foreign Medical School Entering US Residency Programs 1983-1994|
|Data are from the Association of American Medical colleges.|
This program needs to be looked at further with regards to including North American surgeons seeking training abroad. It is clear that in the future more American residents and fellows may be seeking further training and exposure abroad. Cutting edge technology and procedures are becoming more available in Western Europe and elsewhere, where there may be better financial support and decreased bureaucratic constraint. Diseases like rheumatic heart disease and congenital heart disease, especially beyond the neonatal and infancy years, are more prevalent abroad. It will be interesting to see how the vision of American based training programs expands to include sponsored rotations and fellowships in foreign programs.
Surgical training and education in the host or developing programs will gradually evolve. Three movements in this direction have been identified. At the corporate level, industry recognizes the need for training local personal, thus enhancing cardiac surgery capability, and ultimately increasing purchase of product. Examples include the Medtronic School of Perfusion in India. Another is the Baxter Healthcare Asia Pte Ltd. Initiative to develop centers of excellent in India and China. This is an ambitious program scheduled to phase in over an 8 year period (59) . A second movement or initiative involves larger medical institutions or non-government organizations (NGO’s) establishing and sponsoring a center in the host country. Examples include, the ambitious work of Richard Jones, in collaboration with Project Hope, with the Shanghai Children’s Medical Center (60) . Alain Carpentier’s effort to establish the L’Institute du Coeur in Ho Chi Minh City, Vietnam is a testimony to the dynamic efforts of a unique individual and his dedicated team (61) . The third initiative or movement comes from individual surgeons, working alone, in groups, or as part of a major CT surgery society or organization to establish model training programs in selected existing centers. An example is the effort of David Cheung from Hong Kong to establish a model training program in China (62) . This movement has gained momentum with initial interest of the major cardiac centers in Beijing and Shanghai willing to structure a formal CT residency-training program.
Surgical training and education at the international level falls into three categories. The first involves technical or managerial level. This is the basic transfer of knowledge and technical skills, as well as logistical assistance. At the coaching level, organization, and planning are paramount. The third level is crucial. This is the mentor level. It is at this level that the greatest gain is achieved. Loop (63) has summarized the basic concepts of mentoring. Mentors are guides who inspire hope. He divides our professional lives into three phases: education, achievement, and payback. It is the last phase that is mentor time. Interestingly, it is mostly CT surgeons, who, in their final payback phase, find international work most appealing and rewarding.
One of the great challenges or problems in international training in the donor or developed program is dealing with one of four major issues: Firstly, once the FMG gains acceptance to a USA program, logistical problems remain with regard to staying for enough time to complete the specialty training, i.e. visa extensions. Secondly, many do not want to return for personal or financial reasons, or there is no opportunity back home. Argentina is a recent example of this problem. Thirdly, some programs try to entice a talented FMG to stay. Fourthly, some FMG’s return after establishing successful careers in the USA only to find a "lukewarm reception back home".
Research in developing countries is a major concern. This is especially true in research involving human subjects. Suffice it to say USA clinical trials conducted abroad anywhere should conform to the ethical standards based in the United States. The National Bioethics Advisory Commission has published a series of guidelines regarding clinical studies in developing countries (64). The Declaration of Helsinki (65) states:" The benefits, risks, burdens and effectiveness of the new method should be tested against those of the best current prophylactic, diagnostic and therapeutic methods." Again, "At the conclusion of the study, every patient entered into the study should be assured of access to the best proven prophylactic, diagnostic and therapeutic methods identified by the study."
Recently, the Declaration of Helsinki has been further revised to say…"that any treatment being tested in clinical trials should be compared with the best universal standard rather than with a placebo" (66) . Sade and McKneally (67) , representing the STS ethics committee, have recently outlined the responsibilities of investigators. They stress the increasing tenuous relationship between investigators and industry.
Research in the form of writing scientific papers is important. Cooperative efforts with emerging programs generally start with clinical case reports, then small retrospective reviews of their clinical experience (68) . Interesting technical innovations follow (69) . Ambitious prospective studies usually evolve over time. It is here that close mentoring and collaboration with donor groups and centers is most helpful.
Administration/Politic/Logistics (A/ P/ L)
This aspect of international cardiac surgery growth is of extreme importance.
Administration involves the strategy of identifying the opportunity, vision, design,
mission statement, goals, implementation of the plan, and review. Politics involves the subjective aspects of relating and interacting with all the parties involved in the effort. Logistics involves the tactical or managerial effort of transfer and implementation of the plan.
A strategic plan is crucial. A top down strategy occurs at the corporate or society/organization level where an opportunity is identified and research of the project is conducted. Unfortunately, this can be a long, contracted, and often bureaucratic process. Industry has shortened this process by designating specific personal to handle international program development. The Society of Thoracic Surgery (STS) and the European Association of CT Surgery (EACTS) have established ad hoc committees or working groups to deal with international issues and establish an international agenda. The bottom up strategy is the most efficient, insofar as immediate help and design of international clinical programs are concerned. A number of USA teams, so called "Mom and Pop" teams have been active for many years and are very efficient and successful in starting, supporting, and sustaining host programs.
The politics of international work is both rewarding and frustrating. A tremendous amount of time is spent in correspondence, debate, arguments, and compromise. It is clear that we must understand our international colleagues. A thorough knowledge of the host country- its geography, political, economy, social, cultural, religious, and linguistic differences must be understood and appreciated. The expectations of the donor and host country must be outlined and discussed openly and frankly.
The logistical or tactical plan puts into play the strategic plan. On a practical level, all we are really trying to do here is transfer the 3 basics from the donor program to the host program:
The Internet is the principal made of transfer, along with fax, overnight express, cable, and phone. Transfer of people or personnel involves individuals or teams traveling to the host country, or vice versa to the donor country. The transfer of "stuff" or product is a tedious and difficult affair. Most products are donated or bought at reduced cost. With the increase in programs and requirements, donated product has become limited and more accountable. This will become an increasing problem as cardiac surgery programs grow and develop. With limitations in donated product , cooperative efforts and sharing will emerge. As yet, there is no coordinated regional or global effort involving the many cardiac teams venturing "overseas".
The ultimate goal of our vision mission statement is to focus on delivering increased quantity and quality of cardiac surgery on a global level.
International or global medicine is not a new concept. For many years religious and non-religious based medical missionaries have traveled to developing countries to deliver basic medical care. Though religious or humanitarian based, the trust and allegiance they gained has become the foundation on which current strategies are based. Additionally, the corporate world has been involved. In many countries with foreign-based operations, clinics and hospitals were established to care for native workers (eq. Firestone Tire Corporation Hospital in Liberia to care for rubber plantation workers). The military, especially in the United States, has a long tradition of providing immediate, short-term care to non-combatants in foreign countries both in times of war and peace, especially natural disasters. A tremendous effort was made by the former colonial powers to institute health care systems. Great Britain and France, in particular, established basic infrastructure including health care in their former colonies. The legacy remains in many of the colonies, particularly the Anglophone and Francophone countries of Africa.
At present, a variety of international clinical situations exist, relating to cardiac
surgery. The most common include:
Relationships evolve from friendships and trust. These are long lasting and are a source of pride and satisfaction. The heritage of international relationships is long, especially in cardiothoracic surgery. Mark Braimbridge (70) delivered a memorable ode to the whole concept of the international surgeon and the meaning of relationships. The unselfish attitude of CT surgeons is a continued source of pride. He particularly paid tribute to the international vision of surgeons such as Herbert Sloan, Frank Gerbode, Albert Starr, and Denton Cooley. Other examples include China. As China emerged from isolation in the early 1970’s increased contact was made with international colleagues in cardiac surgery. Y. K. Wu, the father of cardiothoracic surgery in China invited international colleagues to China to demonstrate new techniques (71) . Professor T.O. Cheng of Washington, D.C. introduced selective coronary arteriography in 1973. Dr. Domingo Liotta of Argentina in 1974 helped with their first valve replacement. David Bregman, as part of an American Teaching Delegation, introduced intra-aortic balloon pumping in 1980 (72) . Over the years and presently many cardiac surgeons have and continue to donate their time and efforts to reach out to their international colleagues.
Clearly the human factor accelerates this international equation. The ability to make friends, cultivate relationships, and avoid unnecessary "ego wars" is crucial to this whole process. Friendships and relationships are started and nurtured in many ways. Sergeant (73) nicely describes "Le Colloque Singulier". This suggests equality in a relationship. Inequality in medical expertise and resources should not compromise the equality of the relationship. So to, with quality control, there should be a gradual process in emerging programs. Many of these relationships occur during training where FMG’s develop friendships with staff, fellow residents, and other medical and non-medical people. Conferences and meetings is another source of contact where international relationships are spawned and nurtured. It is imperative that the donor individuals and programs treat their hosts with respect and develop a fellowship of understanding and cooperation.
Finances are and will always be a major challenge. An old Italian saying – senza soldi is nati non fanno miracoli (without money the saints don’t perform miracles) is an appropriate comment. This financial aspect is extremely important. Overall global health care spending is beyond the scope of this study. However, certain basics are necessary. Health care spending in the USA is 12-14% of GDP with the average in developed countries reaching 6.9% and developing countries 0.9% (74). Unfortunately, there is no norm or formula to determine what % of GDP should be allocated to health care or human services. The total amount of US foreign aid proposed for FY 2003 is 13.8 billion dollars. This is administered through the U.S. Agency for International Development (USAID). Of this, 2.02 billion is allocated to global health programs <www.globalhealth.com>. The major amount of international health aid comes from the multilateral United Nations (UN) and its major health care arm, the WHO. A number of organized groups are presently engaged in international development and international medical work (75) (Figure 18). Non-government organizations (NGO’s), Private voluntary organizations (PVO’s), and private individual donations constitute the other major sources of international health care funding and spending.
|Table 14. Major International UN Health-Related Organizations74|
|•World Health Organization (\VI-IO)|
|•UN Children’s Fund (UNICEF)|
|•UN Population Fund (UNFPA)|
|•UN Development Program (UNDP)|
|•UN Educational Scientific and Cultural Organization (UNESCO)|
|•Food and Agriculture Organization (FAO)|
|•World Food Program|
|•UN High Commissioner for Refugees (UNHCR)|
|•International Labor Organization|
|•UN Environment Program|
|•UN Fund for Drug Abuse Control|
|•World Trade Organization (½TO)|
In general, there are over 2 million USA based NGO’s, with over 20,000 involved internationally (i.e. in more than 3 countries) (76). NGO’s in 22 of the developed countries generate and spend over 1.1 trillion dollars per year. The major concern or obstacle to enhancing global cardiac surgery growth will be financial funding of any of the mentioned initiatives. Ultimately, the growth of an individual cardiac surgery unit or center will come from the private sector, i.e. "paying patients". Altruistic measures are short term. Corporate donations and sponsorship are short lived. This has become more apparent with more teams seeking a diminishing pool of product for their initiatives and programs. The keys to increased financial support are: 1) cooperation amongst the various groups involved, 2) focused projects supported by grants, etc., 3) government/institution support of the donor/host program, and 4) private sector support, i.e. non government 3rd party payers.
Existing International Activities
The American Medical Association publishes an updated list of non-government organizations (NGO’s) involved with physician service opportunities abroad (77 ).
At the present time there are approximately 20-40 USA based teams or groups doing international work on a short-term basis annually. There are an equal number of teams from the other developed countries. Some notable groups are listed in Appendix Two. A typical team is composed of 10-20 members going to a host country to perform clinical and educational work for 1-2 weeks.
|Table 15. Recent Anecdotal Experiences Reported in Literature|
|LB McGrath, 1992||Tbilisi, Repttblic of Georgia|
|AT Pezzella, 1995||Hanoi, Vietnam|
|HG Horst, 2000||Eastern Europe/Russia|
|AJ Cohen, 2001||7 partner sites (China, Ethiopia, Moldova, Nigeria, Palestinian Authority, Tanzania)|
|A. Kalangos, 2002||Maputo, Mozambique|
The composition of the team usually includes a CT surgeon, cardiologist, anesthesiologist or CRNA, perfusionist, OR and ICU nurses, and a biomedical engineer. Unfortunately, there is no coordinating effort that tracks these programs. Cooperative projects are beginning to emerge as there is a growing interest and necessity to pool information, experiences, and resources, as well as joint cooperative efforts to apply for large financial grants.
"The grand essentials to happiness in this life are something to do,
something to love and something to hope for."
Volunteering to perform medical care is difficult in the United States because of medical/legal constraints and concerns. This is especially true after retirement given the rising costs of malpractice and the particular nuances of hospital credentialing. On the international level the limitations vary from country to country. It is important to learn and understand what the medical licensure requirements are, if any, in the countries served. Additionally, though rare, malpractice issues may be a concern.
There are a variety of ways to become involved. For those venturing for the first time, seeking out individuals or groups with prior experience is the safest and most expedient way to get involved. Unfortunately, there are a limited number of articles in the cardiac surgery literature documenting actual international efforts(78-82) (Figure 19). Once a country of interest is identified, additional information is available. As an example, the Archives of Surgery periodically publishes a special article relating to surgery in a particular foreign country (e.g. Surgery in China) (83). In depth, country profiles are readily available on the internet. (Background notes: http://www.state.gov/r/pa/ei/bgnl)
There has been an increased interest on the part of cardiovascular surgeons to be involved in international activity. Several years ago Heart/Link, an NGO based in Minneapolis, sent out a random survey to cardiac surgeons seeking past, present, or future interest in international volunteer cardiac surgery. Over 150 cardiac surgeons responded (84). Recently, the AATS, under the auspices of Timothy Gardner and Tirone David conducted a survey of the AATS regarding their interest in surgery in underdeveloped countries (85) (Figure 20). 79.5% of responders expressed a positive interest in volunteer efforts. If extrapolated to 75% of the 3,000 CT surgeons in the USA, this represents 2,250 CT surgeons showing interest. Can you imagine the impact of over 2000 cardiac surgery teams being involved in a global effort?
One ‘s own philosophical approach to being involved in the global expansion of cardiac surgery must be addressed and debated. Again, Friedman (12) outlined four political identities in the globalization system (Figure 21). The horizontal line is the globalization line. Separatists reject the concept and tend toward isolationism. Integrationists welcome free trade and Internet commerce. The vertical or distribution axis represents politics and policies. Social-safety-netters seek widespread democracy with social safety nets. The Let-Them-Eat-Cakers is a rugged individualistic, winner-take-all approach. That means less government, taxes, and safety nets. Obviously, the present article tends to be directed toward the integrationist/social-safety-net philosophy. However, the inescapable fact remains that at some point philanthropy and humanitarian assistance is not self-sustaining. Programs will fail unless local support prevails. The best we offer is temporary assistance and hope. Private sector and government support ultimately determines success or failure.
In preparation for a trip, personal considerations include, a valid passport and visa, special geographic needs including appropriate vaccinations, malaria prophylaxis in high-risk areas, medical evacuation insurance, and a thorough knowledge of the host country. Again, general information regarding preparation for short-term or long-term stays in foreign countries is available from the state department http://www.travel.state.gov/americansabroad.html.
Table 16 AATS Questionaire*
No Preference Country
Clinical Area of Interest
Adult Cardiac Surgery (ACS) 55
General Thoracic Surgery (GTC) 34
Pediatric Cardiac Surgery (PCS) 29
ACS and (GTS) 22
ACS and PCS 18
GTS and PCS 2
ACS, PCS, GTS 22
* Personal Communications - James L. Cox MD, past President AATS
From a practical standpoint projects involving international programs should be organized along known models. Most academic cardiothoracic programs work on a four-point model (Figure 22). Using this as an outline helps to guide which areas require the most concern, effort, and interest. Initially the clinical effort is high priority. Trying to do large volumes of cases to cut down the backlog is an obvious goal. The initial clinical concept of teams going for 1-2 week intervals can be expanded to 4-6 weeks intervals. This is accomplished by rotating teams at 1-2 week intervals, and a core group remaining the entire tour. This allows a larger caseload and continuity of care, as well as improved teaching/training efforts. Unfortunately, there is no organized plan amongst the many teams going abroad. Ultimately, as more teams get involved, a consensus will develop to cooperate in terms of personal and resources. Yet, the overwhelming crucial long-term goal is education and training of local teams, as well as providing real time consultation. . This is accomplished by local training and limited/focused training in the donor country. Short-term (1-2 months) training, be it hands-on or not, is very valuable, especially for nurses. Collateral training, i.e. collaboration with existing programs in the region is also an attractive concept that is gaining increased attention. A bold concept regarding education was proposed by Cox (19) . Dividing the world into 3 major time zones would allow real time consultations (Figure 23). Designating rotating surgeons and centers of excellence within the time zones allows readily available consultation for difficult clinical situations. Telemedicine has its most dramatic effect in this area. Further expansion of this modality includes operations, clinics, and educational courses being transmitted to host programs. Research is important initially to gather epidemiological data. The A/P/L arm is the energy source that keeps the engine running. This is the arm that addresses the "ego/money" issues. There are several international models to study and emulate. Professor Alain Carpentiere’s effort in Vietnam is a prime example. The L’Institute du Coeur has grown over a 5-7 year period to over 1200 cases/year.
Hons Borst’s effort in Eastern Europe and Russia is another (80) . In coordination with the EACTS, support of struggling programs has been given in terms of product and educational opportunities in selected Western European programs. This global scheme (Figure 23) can be summarized as follows:
Table 17. Cardiac Surgeon
Average 30-35 year career
3000-6000 open-heart operations/career
3 Phases or Trimester
1—32-35 years of age—42-45 years of age-debt poor; boards; insecure
2—42-45 years of age—52-55 years of age-busy; established; bored?
3—52-55 years of age—62-65 years of age-experienced; what else?
Guidelines for Establishing international Programs/Relationships
Tell me, I’ll forget
Show me and I may not remember
Involve me and I’ll understand
Guidelines for Establishing International Programs/ Relationships
Implementation of program strategies internationally has been previously, described and discussed. Individuals interested are encouraged to contact fellow colleagues already involved. Further sources of information are given in Appendix Two. Corporate contact is helpful since international representatives and regional distributors have a vast knowledge of cardiac surgery activity, or the lack thereof, in their regions. Interestingly, a cardiac surgeon’s career usually expands 30- 35 years from over 30 to 65 or greater years of age. If the average or recommended number of open-heart procedures is 100-150 cases/year/per surgeon then 3000 to over 5,000 cases are done per surgical career. So, over 30 million operations will be done globally over a 30-35 year span. Will that meet the global need and demand?
One can oversimplify and divide a cardiac surgeon’s career into three stages (Figure 24). It is the third phase surgeons or those in semi or full retirement who have the most interest in international activity. Ray Chiu(86) has summarized this group very succinctly : "In terms of human resources for such an endeavor, in addition to volunteer active surgeons, we should not forget the many experienced retired senior surgeons. Their wealth of experience in organizational matters, training and health care quality assurance are invaluable. They are no longer preoccupied by busy operative, academic and administrative schedules, but are still physically and mentally too vigorous to gold and fish full-time. Give them the challenge, and they will help their grandchildren by trying to build a better world in this unique way."
An individual visit to a foreign program as a guest of a local colleague or friend is the most practical way to get involved. Another approach is to accompany an experienced team either as an observer or participant. Beyond that, one can decide whether to continue solo, with a group, or establish his/her own team.
The level of involvement must take into consideration the type of program being considered (Figure 25). The upscale program is an attractive model for individuals or center seeking to gain more knowledge and insight into high technology procedures. Recent examples include the influx of USA based surgeons seeking OPCAB experience at major European centers in Germany and Italy. Another is the robotic experience in the various cities of Norway and Germany. The lateral program has been in vogue for many years. Academic programs have developed a sort of "sister" relationship with varying degrees of formality. On example is the formal exchange program between Sapporo Medical University in Sapporo, Japan and the University of Massachusetts Medical School in Worcester, Massachusetts. The initial program has included exchange of visiting professors for short-term visits to share knowledge and develop future collaborative efforts. The usual relationship involves this initial exchange of visiting professors, and subsequent participation in joint clinical and basic research projects. Short-term exchange of fellows, nurses, and other paramedical personnel is also accomplished. The upgrade relationship is more difficult and enterprising. Many programs have fallen on hard times. The primary need is financial assistance to supplement salaries, acquire/repair equipment, and obtain supplies. They also are in need of added exposure to current and new techniques. The rejuvenated model is again progressively more challenging. Upgrading veteran and recruiting new faculty and personnel is a major effort that requires a long-term relationship.
The de nova relationship is the most ambitious and venturous situation. This involves starting a new program in a hospital area or country where no cardiac surgery has been performed prior. Heart/Link and Save a Child are a few of the organizations with a vast experience in starting new programs (Appendix 2). The basic elements of starting a denovo program, based on personal experience in Haiti, can be summarized as follows: (personal experience, International Children’s Heart Fund) (Appendix 2)
Phase I - specific proposal/plan
A more detailed relationship between a donor and host program includes:
" You’ve got to be careful if you don’t know where you’re going ‘cause you
might not get there.
This review is by no means exhaustive and clearly doesn’t answer all the questions that have and will be raised. We all look for role models and mentors during our cardiac surgery covers. A real and current role model that comes to mind is Sir Magdi Yacoub. This pioneering heart surgeon has found time during his busy practice to venture back to his native EGYPT and perform operations on many Egyptian children as well as train local staff. His recent effort is the establishment in 1995 of the Chain of Hope Charity that provides free heart surgery in Great Britain for children from poor or war-ravaged countries, as well as continuing to develop more centers in emerging countries (Appendix 2). This is but one example of the many others who have been, are, or will be involved in international cardiac surgery efforts.
Corno and van Segesser(88) remarked on the significance of the Rosetta Stone, yet another Egyptian treasure. They stress the power of communication. The documentation on the stone with hieroglyphics is not unlike the major breakthroughs of the internet in allowing the ready transfer of ideas, knowledge, skills, and information. To misquote Benjamin Franklin, individuals are admired for what they do, respected for what they say, and remembered for what they write. The global cardiac surgeon of the new millennium is certainly trained and capable to do all three. What we do and say will be recorded now and discovered in future years in the Rosetta Stone of 1’s and 0’s.
The Importance of Windows
Windows are very good things to have
They let you look out,
And see all the different things.
And they let you look in,
To see all the other different things,
And do you know what is the most
Special window of all?
The window in your heart,
That’s between the Heaven-in-the-earth,
And the Heaven-in-the-sky.
Mattie Stepanek (89)
Appendix One (a)
Official USA State Department Memo
VISAS – INFORM CONSULS
E.O. 12958: N/A
SUBJECT: Revised ECFMG Requirements for Foreign Medical Graduates
1. The purpose of this cable is to inform posts of current requirements necessary for foreign medical graduates wishing to enter the U.S. to take the Clinical Skills Assessment (CSA).
2. The Visa Office has been advised by the Educational Commission for Foreign Medical Graduates (ECFMG), the organization that certifies foreign medical graduates to enter U.S. residency and fellowship programs and conductor of the CSA, of a recent change in procedures. ECFMG reports that a small number of individuals who have attempted to come to the United States to take an examination which is required as part of the certification process offered by the ECFMG may have been disadvantaged as consular officers may be unaware of ECFMGs new procedures.
3. ECFMG certification is required for all graduates of international medical schools as a prerequisite for entry into accredited advanced medical training programs in the United States. In addition to verification of their medical education, applicants must pass four different examinations. These are the United States Medical Licensure Examination (USMLE) Step 1 and Step 2, the Test of English as a Foreign Language (TOEFL) and the Clinical Skills Assessment.
4. The CSA is offered only in Philadelphia; therefore candidates must travel to the U.S. in order to take the examination. Formerly, ECFMG had required that applicants pass both the USMLE Step 1 and Step 2 examinations as well as the TOEFL examination before they were eligible to take CSA. However, those prerequisites were adjusted approximately two years ago. Currently, ECFMG requires that candidates must have passed USMLE Step 1 (or its equivalent) and the TOEFL (or equivalent) prior to taking CSA. Candidates no longer must pass USMLE Step 2 prior to taking the CSA exam.
5. ECFMG reports having received reports from a small number of applicants who claimed that they had been denied travel visas to come to the U.S. to take CSA because they had not passed USMLE Step 2. Obviously, whether this was the actual basis of their denial or not would be known only by the consular officer. However if that were the case it would not be consistent with current ECFMG policy and requirements.
USMLE: United States Medical Licensure Examination,