Time to revisit super-speciality training programs in cardiology in India

Following Independence, Medical Education/Training programs were expanded, with opening of new medical colleges, to meet the growing needs of the country. Some of the old medical schools, which were providing the ‘LSMF’ degree, were also upgraded to medical colleges, to impart MBBS and postgraduate (MD/MS) degrees. In the 1960s, the country witnessed the development of various super specialities in the country. During that time, AIIMS, under the leadership of Late Professor SB Roy, initiated the ‘DM Cardiology’ program, along the lines of the medical board of Cardiology in the USA. Initially the duration of the course was 2 years, but was subsequently increased to 3 years. Other institutions, such as PGI Chandigarh and CMC Vellore, soon followed suit. In the 1970s, The National Board of Examinations (NBE) also started a Diplomate in Cardiology on the pattern of DM (Cardiology), in Private hospitals. These developments led to the growth of dedicated training in Cardiology and also the beginning of Invasive Cardiology in the country, and were also associated with the growth of the cardiac surgical speciality. Today, a number of medical colleges, both the in public and the private sector, are running the ‘DM cardiology’ program. All these have led to an increase in the number of trained specialists in cardiology.

1. Training programs in cardiology – a few thoughts

The standard of training in various colleges/institutes is inconsistent and variable. In the absence of any accreditation body, it has not been possible to monitor and ensure uniformity of training/standards across the country. The MCI grants permission to start training programs and grants recognition to these programs, based on the prescribed minimum requirements of faculty and infrastructure. The MCI does not, however, monitor the quality of training. A few years ago, the MCI constituted a Task Group to examine this aspect. The Task Group submitted its recommendations, titled “Curriculum Guidelines for competency based postgraduate training program for DM in Cardiology”. The MCI should ensure that all institutes follow the laid-down curriculum, so that the residents, at the end of their training, have achieved the desired skills in clinical, noninvasive and invasive fields. The local universities, which conduct the exit examination should monitor standards and ensure that the training is followed as per the laid down guidelines.

It is increasingly being felt that admission to the ‘DM Cardiology’ courses in some private medical colleges is not transparent or fair. It is necessary that a common entrance test be conducted, for ensuring merit as the criterion for admission to these highly specialized courses. For the last few years, the NBE is conducting a common entrance test for admission to speciality and super-speciality courses in their stream, which has generated confidence among the resident community about the fairness of selection.

At present, every DM Cardiology candidate is expected to write 1 or 2 dissertations. Unfortunately, the standard of research is poor, and most dissertations are repetitions of earlier published works with little original research. It is important to ensure that each candidate undertakes quality research, rather than mere repetition of the existing knowledge. This may even inspire and encourage some candidates to pursue academic careers and devote time to much needed original research work in cardiovascular sciences. We need to encourage to innovate for better diagnostic and therapeutic options for various diseases particularly those, which afflict people in India.

Cardiology is a rapidly evolving field with advancement occurring every day; thus training programs would need rapid and regular upgradation. The Task Force should regularly review and suggest the necessary changes in the curriculum and training programs.

At present, we have two streams of training in Cardiology, i.e. ‘DM Cardiology’ which is awarded by the Universities recognized by the MCI and ‘Diplomate Cardiology’ awarded by the NBE. As per the MCI regulations, the two are not considered to be equivalent, especially for the purpose of teaching positions in the medical colleges/institutes. To have two different streams or degrees for the same speciality is counter-productive. It creates confusion, especially when candidates apply for positions abroad. It is time we rid ourselves of this needless and avoidable duplication, and have only one degree in Cardiology and also in other disciplines for all medical colleges and private hospitals. The Government needs to urgently address and take necessary steps to merge these two streams in consultation with MCI and NBE.

2. Development of sub specialities in cardiology

In view of the expansion in the various fields of cardiology, it has become difficult to impart the necessary skills in various fields within a three-year course. It has, thus, become necessary to bring in advanced training in some special field, after DM Cardiology. This is also the practice followed in the developed Western and European countries. There is a need to start a Fellowship training program, with a 1–2 year duration, in some of the sub specialities like:

• 1.Interventional cardiology
• 2.Electrophysiology and pacing
• 3.Heart failure and cardiac transplant program
• 4.Preventive cardiology
• 5.Pediatric cardiology – or course this may now be considered for a separate DM course in view of the expansion of knowledge in this field.
• 6.Noninvasive cardiology
• 7.Molecular cardiology and genetics

The NBE already awards fellowships in Interventional Cardiology, as well as Pediatric Cardiology. Some private hospitals have started a Fellowship in Electrophysiology and Pacing. However, in the absence of recognition by the MCI, these programs are not popular among young cardiologists. Either these fellowships should get recognition, or the colleges and institutes that come within the umbrella of recognition by the MCI must start similar programs, so that the availability of properly trained experts is ensured.

2.1. Manpower and technology development

The Cardiac care story is one of the biggest success stories of modern India. Until the 1980s, and even in the 1990s, patients needing expert cardiac care would rush to Europe/USA. But, since then, the locally available facilities and expertise have created confidence among patients, and one does not hear of patients traveling abroad for cardiac care. We have, at present, highly skilled cardiologists/surgeons who can be compared with the best in the world. The scene has changed to the extent that even patients from other countries come to India for cardiac care and treatment, because of the quality of care and, of course, the comparatively low cost as compared to Europe/USA.

Today, India has a growing patient population suffering from cardiovascular diseases and related complications. According to the ‘Global Status Report on Noncommunicable Diseases 2014’, published by WHO,¹ out of 56 million death in 2012, 68% were attributable to NCDs primarily CVDs, diabetes, cancer, and CRDs. CVD caused 17.5 million deaths or 46.2% of NCD deaths. It is also an established fact that South Asians tend to get coronary artery disease at younger ages, and in more severe form. Life style changes and aging are the two main factors for increase in cardiovascular diseases in our population. Rheumatic valvular diseases also continue to constitute a significant threat to the health and well being of Indians. Thus, India need an adequate number of properly trained and equipped cardiologists, to provide expert care to the needy patients. At present, around 4000 cardiologists are registered as members with the Cardiological Society of India. With the population of the country standing at (approximately) 1.2 billion people, the number of cardiologists comes to 1 for every 300,000 persons. This number needs to increase to, at least, 50 cardiologists per 1 million population, i.e. 1 cardiologist for every 20,000 persons. Thus, there is a significant gap between demand and the available strength. With the present intake, it would take many more years to attain the desired numbers. We need to expand our facilities to train more cardiologists, though, of course, without diluting the standards and quality of education and training. We should also appreciate that many needing developing nations also look toward India for trained cardiologists. Helping these nations will also strengthen and enhance our international image and prestige.

Another important issue is that we are almost totally dependent upon imported material/devices needed for treating cardiovascular diseases. Only limited and sporadic attempts have been made to develop indigenous technology. The first Indian stent, developed by the Defence Research Laboratory, Hyderabad – the “Kalam Raju stent” – gained popularity initially, but this soon declined in view of the better emerging technologies. Some Indian companies are now developing and marketing new drug eluting stents, but there are no comparative data available about the quality and efficacy of these devices in comparison with the new generation imported stents. There is also, at present, no regulatory body in the country to monitor the quality and standards of these stents. Dr. M.S. Valiathan, former Director of Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thirvananthapuram, Kerala, India is credited with making the first Indian heart valve, which is quite cost effective and has turned in good surgical results. Still, almost the entire bulk of consumables for various procedures, such as stents, devices for defect closure, valves (prosthetic/bioprosthetic), pacemakers, ICD's, balloons, and RF catheters are being imported. All these have kept the cost of these procedures high, virtually beyond the reach of many of our patients, who really need and benefit from these treatments. We need to take measures on a war footing to remedy this, and provide high quality low cost alternatives to our populace. The pharmaceutical industry certainly deserves to be lauded for producing many cheap generic drugs for cardiac patients.

It is, thus, time we take necessary steps to expand and improve quality training in cardiology to have the necessary skilled/expert manpower to fulfill our needs. Academia and industry should join hands to invest in cardiovascular research for innovation to generate new drugs/devices so as to make available diagnostic/therapeutic procedures at affordable cost. Let us take the desired steps and strive hard to be among the world leaders in cardiology.

Conflicts of interest

The author has none to declare.