Paths for Cardiothoracic Surgery Training in Nigeria: The journey towards indigenous open heart surgery programmes Dr Uvie Onakpoya Obafemi Awolowo University Teaching Hospital, Ile- Ife, Nigeria. 1
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West Africa 3
Demographics Population- 317 million 15 countries Languages: Anglophone Francophone Lusophone 4
CT Surgeons ratio Country Population % of whole CT Surgeons Ratio Nigeria 180,507,573 55.0 44 4,102,444: 1 CTs Ghana 24,304,000 7.7 8 2,700,444: 1 CTs Cote D Ivoire 21,504,162 6.8 9 2,389,351: 1 CTs Niger 15,085,000 4.7 Burkina Faso 15,034,000 4.7 Mali 13,803,000 4.3 Senegal 12,643,799 4.0 5 2,528,760: 1CTs Guinea 10,589,000 3.3 Others 30,153,135 9.5 TOTAL 317,623,669 100 66 5
Training Programmes Regional West African College of Surgeons National National Postgraduate Colleges especially the Nigerian college Fellowship programme in Cardiothoracic Surgery 6
General Survey of the Cardiothoracic Surgery Programme (1) Primary Examination in Basic Sciences A pre- residency programme Curriculum includes: General anatomy Applied physiology Biochemistry Pharmacology Pathology The Faculty of Surgery organizes a 4-week revision course for all candidates 7
General Survey of the Cardiothoracic Surgery Programme (2) Junior Residency (30 Months) General Surgery Orthopaedics Accident & Emergency Anaesthesia: Urology Rural Surgery rotation Electives (Paed Surg./ CTS/ NS/Plastic S) 9 months 3 months 6 months 3 months 3 months 3 months 3 months Success in the part 1 fellowship examination is a prerequisite to admission into the senior residency in Cardiothoracic Surgery 8
Overview of Senior Residency in Cardiothoracic Surgery Rotations Duration (Months) General Thoracic Surgery 24 Cardiac Surgery 12 Vascular Surgery 6 Cardiology (Adult & Paediatric) 3 Cardiopulmonary Imaging 3 Total 48 9
Course Credit Allocation (I) Lectures/ Seminars (10 credit units/ 3 months) 2 Hours daily i.e. 10 hours/ week (1 hr/ week for 3months = 1 credit unit) Practical Skill Acquisition/ Clinical Exposure (10 credit units/ 3 months) 10 hours daily i.e. 50 hours/week (5 hrs/ week for 3 months= 1 credit Unit) *Total of 20 credit units every 3 monthly rotation 10
Course Credit Allocation (II) Dissertation Project (20 credit units) The Minimum total credit to qualify for the Part II final fellowship examination is 340 credit units 11
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway 12
Pathways for training in the US 1. Traditional pathway 5 years GS + 2-3 years CTS Additional 1-2 year sub-specialization fellowships if desired in: Congenital heart surgery Thoracic Surgery Transplantation Thoracic aortic surgery Surgical management of heart failure 13
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway 6- year rotations consisting of: Adult cardiac surgery- 21 months Thoracic surgery- 20 months General surgery- 18 months Paediatric cardiac surgery- 6 months Vascular surgery- 2 months Cath lab/ echocardiography- 1 month Cardiac anaesthesia/ critical care- 4 months 14
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway PGY1 Thoracic surgery- Cardiac anaesthesia/ CC- Adult cardiac surgery- General surgery- 2 months 2 months 2 months 6 months 15
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway PGY2 Thoracic surgery- Cardiac anaesthesia/ CC- Vascular surgery- Adult cardiac surgery- General surgery- 2 months 1 month 1 month 2 months 6 months 16
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway PGY3 Thoracic surgery- Cardiac anaesthesia/ CC- Vascular surgery- Cardiac cath/ echo- Adult cardiac surgery- General surgery- 1 month 1 month 1 month 1 month 2 months 6 months 17
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway PGY4 Thoracic surgery- 6 months Paediatric cardiac surgery-6 months 18
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway PGY5 Thoracic/ adult cardiac surgery- Adult cardiac surgery- 6 months 6 months 19
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway PGY6 Thoracic/ adult cardiac surgery- 12 months 20
Pathways for training in the US 1. Traditional pathway 2. Integrated pathway (I-6) 3. Fast-track pathway General surgery- 4 years Cardiothoracic surgery- 3 years 21
103 registered CT surgeons in SA by 2015 Considering an exchange programme with Israel for residents and consultants Commencement of Resident s forum in 2000 22
Training of CT surgeons has become increasingly complex and faces unique global challenges due to: Escalating institutional costs Declining faculty interest Expertise and dedication to training Trainees concerns with respect to length of training Decreasing volume of cases Uncertainties with regards to competence and future employment 23
Israeli CT training programme TOTAL LENGTH OF TRAINING Cardiac track Thoracic track Cardiothoracic track 6 years 6 years 7.25 years - CT surgery 4 years 4 years 5 years - General surgery 1 year 1 year 1 year - Anaesthesia/ critical care 3 months 3 months 3 months - Cardiology 3 months Not required 3 months - Pulmonary medicine - Basic science research Not required 3 months 3 months 6 months 6 months 6 months 24
Israeli CT log requirements Cardiac track Thoracic track Cardiothoracic track CABG 40 Not required 40 Valve operation 10 + 5 Not required 10 + 5 Congenital heart operation Any cardiac operation Any pulmonary resection Oesophageal operation Pulmonary diagnostic procedure 10 Not required 10 20 15 60 60 Not required 5 5 Not required 20 20 25
Balram Airan, former president of the Indian association of cardiovascular and thoracic surgeons states: Residency training in our specialty is losing glamour There are no uniform training programmes in India Many hospitals provide false information to accreditors CT residency was not the first choice in PG admissions Though training in general surgery offers fundamentals of surgical principles, I do not believe that a 3- year residency in general surgery is required before entering a cardiothoracic surgical training programme 26
Course Content (Lectures/ Seminars) General Principles 27
1. General Principles Embryology of the heart, great vessels, chest wall, lungs, diaphragm Physiology of neonatal circulation Morphology & Classification of congenital heart diseases Haemostasis, anticoagulation & anti-platelets Cardiopulmonary Resuscitation Investigations in cardiothoracic surgery Pathology of emphysema and tumours of the chest and heart 28
Course Content (Lectures/ Seminars) Endoscopy 29
2. Endoscopy Indications and complications of: Laryngoscopy Bronchoscopy Oesophagoscopy Thoracoscopy Mediastinoscopy 30
Course Content (Lectures/ Seminars) Thoracic Surgery 31
3. Thoracic Surgery Congenital diseases of the lungs and oesophagus Chest trauma Infective problems and their complications Oesophageal diseases Obstructive and restrictive airway diseases Thoracic tumours 32
Course Content (Lectures/ Seminars) Cardiac Surgery 33
4. Cardiac Surgery Principles of cardiac catheterization Management of congenital heart diseases Valve design and construction Management of Acquired valvular diseases Ischaemic Heart Disease Arrhythmias including Pacemakers and ICDs Pericardial diseases Pulmonary embolism Cardiac Tumours 34
Course Content (Lectures/ Seminars) Vascular Surgery 35
5. Vascular Surgery Management of Deep venous thrombosis and diseases of the superficial venous system Peripheral vascular diseases Vascular trauma Dialysis Access Vascular malformations Management of Aneurysms 36
Course Content (Lectures/ Seminars) Transplant Surgery 37
6. Transplant Surgery Cardiac and Lung transplantation Mechanical Circulatory Support Organ retrieval, preservation and monitoring of rejection Harvest and utilization of homografts in congenital heart surgery Cardiomyoplasty 38
Course Content (Lectures/ Seminars) Principles of Research 39
7. Principles of Research Audit and analysis of scientific data Research methodology 40
Log book of procedures 41
Log book 2 Thoracic Surgery Contd Decortication Pleurodesis Thoracoplasty/ Chest wall resection Sleeve resection of the trachea/ bronchus Bronchial stents Operations for emphysema & Bullae Correction of pectus deformities Oesophagectomy/ oesophageal replacement Operations for hiatus hernia/ GERD Thymectomy VATS Cardiac Surgery Pacemaker implantation Valve surgeries Pericardial surgeries Operations for aortic dissection Operations for congenital anomalies Cardiac transplantation, LVAD Others Peripheral vascular surgery Trauma PAOD Dialysis access Resection of aneurysms 42
Accreditation of Training Institutions 2-3 yearly visitation panels 7 Partially accredited hospitals (Nigeria) 4 Fully accredited centers (Nigeria, Ghana, Cote D Ivoire &Senegal) 43
Pathways for the Nigerian CT resident 44
Problems with the West African Training Programme Low cardiac surgical Volumes Low- expectation training period for cardiac surgery 45
Low cardiac surgery Volumes WHO estimates of cardiac surgery- 400 OHS/ 1 Million population/ year West Africa with a population of >300 million needs to perform 120,000 OHS per year In 2015, <600 OHS were performed. Inadequate for training the 40 senior residents in West Africa. 46
Vicious Cycle Regional Instability Few Cardiac training centres Low Cardiac Surgery Volumes Poor health insurance Poor funding 47
Low- expectation training period for cardiac surgery Increasing the cardiac surgery contact time of trainees Incorporation of training in high volume centres Exchange programmes Increasing the local cardiac surgery work load Workshops and wet labs on valve replacement, CABG, Vascular surgery etc Animal Research laboratories Consideration of integrated 6-year Cardiothoracic Surgery Residency Programme??? 48
Challenges Setting up a new or continuing an existing open heart surgery programme is multifactorial: Government Institution provision of infrastructure, equipment and other facilities Cardiac team training Appropriate funding of patients 49
Towards indigenous cardiac surgical programmes Have we ever done an audit on our curriculum? Have we tracked the progress of our trainees in the West African or National programmes? Has any trainee who finished the approved training programme gone on to establish a thriving open heart surgery programme in his institution in Nigeria? Has any trainee of our programmes gone on to continue previously established cardiac surgical programmes in Nigeria? Of the centres in Nigeria currently doing indigenous open heart surgery, are any headed by our regional trainees? Does training just the surgeons translate to viable local cardiac surgical programmes? 50
Recommendations Training of local teams (Surgeons, cardiologists, anaesthestists, nurses, perfusionists, biomedical engineers, cardiac physiotherapists etc Partnership with active and friendly cardiac surgical teams to prevent cardiac missions addiction Charting a pathway and time frames for conversion to independence Re-training and building of local teams Appropriate billing and funding of patients Financial autonomy Phased transfer of responsibilities to the local team Local team starting with well selected, simple cases Phased performance of more complex cases 51
Wholly indigenous OHS at Ile- Ife 52
To our wonderful patients
To my teacher, Dr David Mishaly, Sheba Medical Centre, Israel
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