Abstract
Tell me and I forget, teach me and I may remember, involve me and I learn.
—Benjamin Franklin
Medicine is considered a noble profession globally as it deals with managing patients’ lives and restoring them to a normal life. Following MBBS, medical graduates pursue MD/MS postgraduate training in a particular specialty for three years. The postgraduates, with an unquenchable thirst for knowledge and excellence, pursue super specialty courses (DM, MCh, or DrNB) in their chosen specialty for another three years. Post-DM/MCh/DrNB fellowship training programs are offered in respective areas of specialty to gain precision and expertise in subsets of chosen specialties (which are of duration 1–2 years). A medical student must endure 10–12 years of laborious, cumbersome training to evolve into a superspecialist to accurately treat diverse patients in the society.
While MD/MS training happens in government hospitals in the public sector, DNB training happens in private teaching hospitals. Both have different curricula and exam patterns. Similarly, DM/MCh is the training done in government colleges and institutes, whereas DrNB is done in private hospitals. However, the entrance exam to get a seat in either has been the same (NEET) over the past few years. 1 Unlike MBBS and MD courses, which have a structured program for what to be dealt with, the DM/DrNB training does not have a program for the specialties concerned with what to be dealt with. The National Medical Commission (NMC), since its inception in 2020, has introduced a competency-based program for PG training in each specialty over the years. 2 Modern-day cardiology practice has advanced by leaps and bounds compared to that a century ago. However, for cardiology, it has not been introduced.
This radical contrast is fueled by a deeper understanding of the disease pathology, enabling early diagnosis and corrective interventions. Technological advances in drug discovery, using applied artificial intelligence (AI), predictive modeling, harnessing digital data, and nanotechnology-enhanced bio-devices, have led to effective management. On the other hand, with urbanization and a rise in sedentary behaviors in the backdrop of a population explosion, especially in a post-pandemic world, the demand and urgency for medical professionals are at an all-time high. On the contrary, the conventional pace of current medical training to churn out cardiologists is tediously slow, magnifying the supply–demand lacunae.
Does Cardiology Training Necessitate a Revamp to Match Emerging Needs of the Community?
DM cardiology calls for a structured program with a well-thought-out, standardized curriculum regarding what to train in this three-year course. Further training is required because of the enormous increase in the understanding of pathologies and advancements in heart disease. This article attempts to dissect this problem and offer potential insights to bridge the gap, as I summarize my perspectives gained over the past two decades of my career as PG teacher.
Compared to two decades earlier, the chances of getting into the DM/DrNB course are easy, with an increased number of seats in institutes nationwide. However, this rise in the number of seats is not matched with the increase in the quality and rigor of training. There are various reasons. For any candidate opting for cardiology, getting in tune with training takes around two to three months, especially those coming from other branches (pediatrics and pulmonary medicine, for various reasons).
Thirty-six months of training is ample time for a candidate in diagnosing and managing heart disease. What has affected the training of cardiology over time? The following elements stand out conspicuously.
Passing MD has been only a gateway to getting into the DM course rather than being essential for understanding heart disease (a good superspecialist should be a good physician initially). Candidates should be exposed to clinical material post-MD of their course before getting into the DM course so that they can apply the knowledge gained in managing cases.
Knowledge with practice is practical. Practice without knowledge is dangerous.”
—Confucius
The need for adequate staff to train candidates has decreased. Previously, there used to be one candidate and five to six teaching faculty; now, each faculty has two to three candidates with the availability of the same material (the clinical exposure frequency and quality have decreased). The increased awareness of the disease, conscious health-seeking behavior, and increased population longevity have led to an unprecedented surge in patient load.
The COVID-19 pandemic has affected lives globally and seriously impacted training sessions of candidates in their respective departments.3, 4 Managing cases was the top priority during the time, and every recruited doctor was posted to manage them, many of whom succumbed to it during their service. Subsequently, the three-year batches were given relaxation in fulfilling the criteria for training for the services rendered. A couple of years later, when the pandemic weaned off, residents lost their groove of going back to the track of clinical examination and making a confident diagnosis without imaging. Due to the dearth of clinical cardiology and the risk of exposure to contact with patients, the clinical examination touch has been lost.
In due course, physical examination has lost its importance. For example, “Pulsus paradoxus” is hardly elicited nowadays, missing the cardiac tamponade as a clinical diagnosis, which is an emergency. Instead of a clinical assessment, the diagnosis is based on echocardiography. Pericardiocentesis is a cath lab procedure, with intra-pericardial pressures and tracings playing a role in management, which has become a bedside procedure of late. Cath data on congenital heart disease is hardly done nowadays, given the advances in echocardiography. Hence, the interpretation of cath data is hard for current postgraduates.
Medicine is learned at the bedside and not in the classroom. Let not your conceptions of disease come from the words heard in the lecture room or read from the book. See and then reason and compare and control. However, see first.
—William Osler
The major change during the pandemic was an enormous increase in the availability of online clinical materials, leading to various views and anecdotal approaches. This, along with no exposure to teaching and hands-on training during those three years, led to candidates relying on the former rather than on the traditional approaches. It is high time for the faculty to guide on what is needed for a candidate.
A student pursuing DM/DrNB cardiology is usually married and has to lead a family. There is increased stress in managing both. Some of them succumb to the stress, ending in suicide. The stipends and post-DM salaries in the teaching institutes are less. So, most candidates decide to work in a private institution or get into practice to meet their needs rather than choosing a teaching profession.
Lack of effective communication between doctors and patients leads to assaults on doctors. The communication and confidence of patients have to be gained before proceeding further, which is lacking in most budding doctors. Budding cardiologists are in a defensive mode for many reasons and rely heavily on addressing the battery of investigations to escape the risk of being sued later.To make both ends meet, the training must be changed relatively, which has been fixed on age-old methods.
Teaching Methods
The curricula and exit exam are to be the same for both DM and DrNB cardiology. The traditional clinical materials (old editions of Perloff Clinical Cardiology, Braunwald’s old editions, Alpert Valvular Heart Disease, etc.) should be available in all the teaching institutes. There should be an orientation class before each posting (in the intensive cardiac care unit, echocardiography lab, or cath lab) for the postgraduate so that he or she knows what to do during the posting. Postings in cardiothoracic vascular surgery, pediatric cardiology, electrophysiology, cardiovascular imaging, heart failure clinics, cardio-oncology, research, etc. spanning over two to four months are required for exposure to all subsets of cardiology. There should be a test at the end of each training session to assess what has been learned. A logbook should be maintained and reviewed by the faculty often. Guest lectures should be done by electrophysiologists, pediatric cardiologists, and cardiothoracic surgeons (interdepartmental) on approaches to different cases. Interzonal CMEs should be organized by respective universities. An e-library with all important articles, presentations, and video demonstrations should be made available for quick reference. With faculty presentations, the student knows the presentation skills, how to deliver a talk, and approaches to the diagnosis of heart disease. Finally, postgraduates should be encouraged to do an effective dissertation with innovative thoughts under supervision rather than modify the previous dissertation done years ago. The necessary support from a grant for the dissertation should be made available in case of monetary issues.
Internal Assessment
Internal assessments every six months in the department, assessing the candidate’s capability in diagnosing, managing the case, and clinical application, are of importance. There should be weightage for internal assessments. After the training in the subset, there should be short assessments covering the format of regular questions, multiple-choice questions, and objective structured clinical examinations, apart from the actual case scenario format. The candidate should be informed regarding his or her lacunae and be encouraged to improve over the course.
Final Examination
The exam pattern must change as it differs from state to state, between private and government, and between DM and DrNB courses. A common exam protocol for both is to be followed. The theory exam should consist of two papers on each day, each lasting 90 minutes, instead of 180 minutes. One should focus on theoretical aspects, and one should address the clinical application apart from the usual practical exam.
Clinical practical cases are to be uniform, all carrying equal marks. The assessment should shift from rheumatic valvular heart disease to ischemic heart disease, heart failure, and complicated hypertension management. Instead of relying on the structured protocol of cases, it should be focused on how to manage the cases seen in daily practice. An assessment of the candidate must be done based on how well he or she can do a procedure (knowledge-based assessment, for example, doing angiography on a mannequin, how to deliver a DC shock, management of arrhythmias).
The viva voce should specifically address other aspects of cardiology, covering all core topics as per a universally proposed protocol rather than asking the questions as per the examiner’s interest. Bedside rounds and pedagogy should be given importance.
It is time to adapt to the emerging needs of the communities, without compromising on conventional training standards, teaching rigor, and quality clinical exposure. While it is wise to leverage technological advances to improve patient outcomes, it is deleterious to think that technology is a substitute for the clinical acumen of the treating physician. Technology is a supplement, not a substitute for human intelligence. The emerging crop of cardiologists training should optimize conventional gold standards in teaching while blending technical advances and evidence-based medicine into clinical practice.
