Indian disenchantment in cardiovascular and thoracic surgery: a national or a global threat?

According to sources, a “motivator” is a person or thing that makes someone enthusiastic about doing something and a “barrier” is a long pole, fence, wall, or natural feature, such as a mountain or sea, that stops people from going somewhere (https://dictionary.cambridge.org/dictionary/english). Having said that, the study recently published by Idhrees et al. in the Indian Journal of Thoracic and Cardiovascular Surgery [1] brings important information, actual data, that sheds light on the current situation of cardiovascular and thoracic surgery (CVTS). This study addresses the impact of surgical trainees declining a career in our specialty which may have an impact on our future.

The fact is that, regardless of the route of entry to a CVTS program in India, the percentage of vacancy in 2019 and 2020 reached a stunning 72%. Pediatric surgery lies behind with 62% and other specialties have much lower percentages of vacancy. It seems then that the future of CVTS could be somewhat unstable due to the inability to recruit sufficient trainees in India to ensure an appropriate generational transition and the solidity of the specialty. Is this a wake-up call? A voice of alarm?

After a thorough analysis of multiple variables investigating the pros and cons of choosing a given surgical career, the authors concluded that the “motivators” for CVTS are that this is a dynamic and daring, and intellectually challenging specialty and that there is a component of prestige being a cardiothoracic surgeon. On the contrary, some “barriers” were identified such as the need of a hospital setup with sophisticated infrastructure, the dependence on a multi-disciplinary team, a poor lifestyle and work-life balance, high intensity of work, and the time to become an individual consultant [1].

Overall, CVTS in India seems to move forward on shaky ground as education may be under threat. Idhrees et al. [1] are on the right track when stating that training in CVTS faces multiple challenges. The boom of transcatheter therapies observed in the last two decades, the growing trend towards minimal access surgery, and the increasing surgical complexity are some of the limitations to offering a complete training today. The “barriers” identified are not exclusive of India. A recent survey among 289 staff surgeons and residents in training from 18 countries in Latin America published by Marin-Cuartas et al. [2] highlighted similar problems in training and practice such as dissatisfaction with income, the difficulties in reaching a leadership position, the difficulties in finding a job after completing training, and that in 47% of the cases the training spots remained vacant. Seventy percent of the participants notwithstanding would choose the specialty again, as it is appealing and therefore a “motivator.” An important difference between India and Latin America is that there is no cardiac surgery board examination in the latter [2].

This apparent threat to CVTS education and practice seems to be a global phenomenon. Keeping in mind the variety of training systems and practice patterns, restrictions and limitations to training and practice are also related to administrative policies and regional politics. An example is that of the European Working Time Directive (EWTD), an old story [3]. Two decades after the implementation of the EWTD which restricts the maximum working hours for trainees to 48 a week, there is still controversy as to how positive/negative this EWTD is. Its impact may change according to specialty [4]. There are still controversies among trainees with regard the EWTD with 56% not satisfied with their training opportunities according to a recent European survey [5]. More specific studies in a high-volume center confirmed that the implementation of the final phase of EWTD did not decrease training in a high-volume center over two periods of time due to internal adjustment of trainers’ attitudes and efforts to match the needs of the trainees [6]. This was a continuation of a previous initial experience on exposure to operative cardiac surgical training [7]. A major issue with these studies is that they only analyzed the caseload of the trainees, leaving aside the fact that training in cardiothoracic surgery is a more complex process than acquiring manual skills. On the other hand, the survey of Sadaba et al. [8] clearly indicated that a large proportion (60.5%) of European trainees were dissatisfied with their training and reported low levels of regular assessment of their progress and of training facilities. All of this was addressed by us when the EWTD was to be implemented across Europe [9]. Once more, it seems that 20 years after the implementation of the EWTD, compliance is still low with a number of differences between specialties and centers. What is probably needed to implement such a Directive is having manpower and money. Manpower could eventually be available at a very low cost (the reality) as money seems to be a major global problem, too.

Further to the identification of their “motivators” and “barriers,” Idhrees et al. [1] have issued some recommendations aiming at tackling the problem that include, among others, mentorship, societal fellowship and a career-building task force, and great initiatives. As they also highlighted some of the major challenges, it seems clear from their data that an adoption of an innovative model of training and practicing is to be considered and the curricula will need to evolve in the direction of teaching and of cross-fertilization learning programs in which not only surgical caseload but a solid intellectual component must be considered, as education is the foundation of future surgeons and leaders [10–12].

As said, the problem is not restricted to India and cardiothoracic surgery. It is probably of global reach and affects the entire medical profession. There are a number of extraprofessional factors to consider which are not exclusive of a given country. Mismanagement and bureaucracy play a major role in planning and execution. The South African Heart Association is concerned about the government reduction of training posts in cardiology and cardiothoracic surgery and confirmed profound deficiencies in training and delivery amidst an inappropriate environment, despite acknowledged major challenges [13]. In Spain, 25,000 physicians left the country seeking for a better job and compensation in the past 10 years. A similar problem involves nursing professionals. An estimated 70,000 physicians will retire within a decade and replacement is already a major issue due to severe deficiencies in planning (www.lavanguardia.com/vida/20221015/8567769/escasez-medicos-exceso-trabajo-ponen-riesgo-sistema.html). Is this another hint of an expectable system crack down?

Although it sounds that we might be at the verge of an apocalyptic scenario (who knows), and once more paraphrasing Idhrees again [1], we must say that cardiothoracic surgery remains a rewarding and fulfilling field that continues to evolve based on the needs of the population; it is alive and has a bright future. And on “motivators” and “barriers,” Dhoni vs the wicket?

Funding

None.

Declarations

Ethics approval

This study did not require Ethics Committee/Institutional Review Board approval as it did not represent human research.

Informed consent statement

Not applicable.

Conflict of interest

The authors declare that they have no conflict of interest in this study.

Statement of human and animal rights

Not applicable.