Author + information
- Ankur Kalra, MD∗ ()
- Minneapolis Heart Institute at Abbott Northwestern Hospital and Department of Medicine, Division of Cardiology, Hennepin County Medical Center, Minneapolis, Minnesota
- ↵∗Reprint requests and correspondence:
Dr. Ankur Kalra, 701 Park Avenue South, Cardiology O5, Minneapolis, Minnesota 55415.
My cardiovascular disease fellowship training program offered a unique opportunity to organize a fully-funded international elective during the second year of fellowship. When deciding to become a cardiologist, I knew that I wanted to have exposure to cardiovascular disease states infrequently encountered in the United States. Although I was interested in pursuing a career in structural interventional cardiology, I wanted to gain more exposure in pediatric and adult congenital heart diseases, with a particular focus on percutaneous transvalvular therapies, balloon mitral, and pulmonic commissurotomies. Presented with this international elective option, I chose the All India Institute of Medical Sciences (AIIMS) in New Delhi, India. This institution is a strong, federally-funded medical school and teaching hospital in India, treating complex pediatric and adult congenital heart diseases as well as rheumatic heart disease cases that are referred to New Delhi from elsewhere in the country (1). The AIIMS caters to unprivileged and uninsured patients, offering the best evidence-based, state-of-the-art care that it can, given the lean budget allocation for healthcare expenditures in India (2).
To gain entry into the program, the initial process involved an application to be approved by the program leadership, as funding was only available for 2 fellows per year. The application form required the fellows to describe the intended rotation, to indicate how the rotation related to their future career and professional goals, and to briefly describe a project that the fellows were required to do in relation to the rotation, with the intent of advancing care locally. Because my fellowship took place across 2 hospital sites, an approval committee was established to review the fellows’ applications. For a site to be approved for the elective, 1 of the more stringent requirements was that the experience gained must be an enhanced educative experience for the fellow that was not otherwise offered in-house by the fellowship program. The process also involved simultaneously contacting the person in charge for arranging the international electives at the selected site, which required another application form to be filled out and submitted along with supporting documents at the institution’s registrar office. As this was a multistep process that required advanced planning and paperwork, I started the process approximately 9 months in advance of the proposed travel. This also required me to arrange rotations to fulfill my goals for the Core Cardiology Training Symposium requirements.
The experience that I gained during my 4-week elective, however, was well worth the effort. As my elective was primarily focused on gaining exposure in pediatric and adult congenital heart disease interventions, as well as in percutaneous mitral and pulmonic transvalvular therapies, my typical day started at 8:00 am in the cardiac catheterization laboratory with the morning report, where the overnight in-house fellow-on-call presented cases that were performed in the catheterization laboratory. All of the fellows were expected to be present and to answer questions from senior faculty related to the cases. The daily session, based on the Socratic method of teaching (3), was a tremendous hour of learning for the fellows and early career faculty members.
The cardiac catheterization laboratory at the AIIMS assigned particular days of the week for pediatric and adult interventional cases. Tuesdays and Thursdays were pediatric days, and the rest were adult coronary and structural days. Unlike a typical U.S. schedule, Saturdays were working days, albeit only until noon, and were mostly reserved for fellow didactics. Although I participated in coronary interventions during adult catheterization days with other fellows, the “steep learning curve” experiences occurred during pediatric catheterization days. A typical pediatric day had approximately 20 to 30 cases scheduled, and the vast majority of the “line-up” of cases included tetralogy of Fallot patients. The exposure to other congenital heart disease cases, however, was an incredibly informative aspect of my elective. For example, I saw cases of anomalous left coronary artery arising from the pulmonary artery, anomalous right coronary artery arising from the pulmonary artery, tricuspid atresia with restrictive ventricular septal defect and pulmonic stenosis, supracardiac total anomalous pulmonary venous return, sinus venous atrial septal defect with partial anomalous pulmonary venous return, and persistent left superior vena cava. One of the fellows in the program, a colleague of mine from residency days at the AIIMS, also shared case files of other congenital heart disease cases that included transposition of the great vessels, hypoplastic left heart syndrome, and congenitally-corrected transposition of the great vessels. All of these cases were brought to the cardiac catheterization laboratory, and ventriculograms and aortograms were obtained to establish the respective diagnoses. Fellows-in-training were primary operators in all diagnostic procedures, an experience that is infrequent, and often nonexistent, in adult cardiovascular disease training programs in the United States.
Another highlight of the elective was the exposure to adult structural interventions. The laboratory performed 3 to 4 mitral commissurotomies per day, in addition to percutaneous atrial and ventricular septal defect closures. Although I was primarily scheduled to be in the catheterization laboratory during the elective period, I was also exposed to managing patients with short-QT syndrome, arrhythmogenic right ventricular cardiomyopathy, twiddler’s syndrome, pre-excited atrial fibrillation, ST-segment elevation myocardial infarction treated with thrombolytic therapy, ruptured sinus of Valsalva aneurysm, supravalvular aortic stenosis, cor triatriatum, and cardiac rhabdomyoma. There were no duty hour regulations, as there are in the United States. The fellows were on an in-house 36-h call schedule, with the first-year fellows taking a fair percentage of calls upfront.
Another requirement that the program leadership had established for the international elective was to partake in a project that helps to advance care locally. India is the second most populous country in the world, with a significant burden of cardiovascular diseases (4). No formal referral program for hypertrophic cardiomyopathy (HCM) currently exists, and there is no “center of excellence” in India where HCM patients can be referred for initial evaluation, risk stratification, and risk management, and followed-up longitudinally. I worked with Dr. Barry J. Maron to propose a hierarchical model for developing such a center in India. We have identified 5 centers in India with such initial interest in HCM (4).
Doing this international elective was an enriching experience, not only to expand my knowledge in cardiovascular medicine, but also to establish international collaborative efforts that will help advance care locally for the community. Fellows who are interested in international elective opportunities should be proactive in communicating this request to their program directors. The American College of Cardiology has an international center that lists a repository of sites in more than 20 countries and across 40 institutions worldwide that are willing to accept fellows-in-training and early career physicians for such electives (5). As these electives are usually self-funded, it is important for the fellows to inquire if their programs will continue to provide bi-weekly stipend while they are away, working on an international site. Other important logistical issues include arranging visas for travel, inquiring about vaccination and chemoprophylaxis for endemic disease states, and lodging. In addition, it is also important to inquire whether the site will offer hands-on training opportunities for fellows, and whether a U.S. medical license is valid in the country where the elective is arranged. There is a lot to be learned from the practice of medicine and cardiology in resource-limited settings, and fellows-in-training in the United States can benefit tremendously from such an experience, while also contributing to and collaborating in quality improvement in healthcare delivery in such settings.
- William A. Zoghbi, MD, Past President, American College of Cardiology; Director, Cardiovascular Imaging Institute; Elkins Family Distinguished Chair in Cardiac Health; Houston Methodist DeBakey Heart & Vascular Center
RESPONSE: The Benefits of Cross-Cultural Training
It was heartening to read Dr. Kalra’s account of the enriched training he experienced during his international elective in congenital and structural heart disease in India. While the United States and other developed countries have state-of-the-art technology, developing countries offer settings that cultivate vital clinical skills in observation, patient interaction, and resourcefulness. Not only do the variety of pathologies and interventions rapidly broaden one’s experience, but the chance to observe seasoned physicians creatively treat patients against a background of scarce resources can teach us a great deal about what really matters in health care. Clearly, one does not need the most advanced technology to provide high-quality care.
While many foreign graduates would love to come to the United States and be exposed to the latest technology, Dr. Kalra’s experience will hold appeal for many American and European trainees. I applaud the fellowship program at the Minneapolis Heart Institute and Hennepin County Medical Center for allowing such an elective and for meticulously defining goals for the trainees. Many programs may not have the dedicated resources to relinquish a trainee of their services for a few months, but shorter exchange programs could still be beneficial.
Fortunately, a growing number of health care facilities around the globe show interest in receiving outside trainees or observers, and these are listed on CardioSource. Connecting physicians across the world through education has been a legacy role of the American College of Cardiology (ACC) since its inception (1,2). Now, the ACC has 32 chapters around the world, with close to 10,000 international members. Reaching beyond our own cultures—be it during training or later in our cardiology career—can enrich our education and knowledge in countless ways. I hope many will follow Dr. Kalra’s footsteps.
Dr. Kalra has a financial interest in Kalra Hospital in New Delhi, which may begin delivering the hypertrophic cardiomyopathy services described in this paper.
- American College of Cardiology Foundation
- ↵India Today. India's best arts colleges 2011. Available at: http://indiatoday.intoday.in/bestcolleges/2013/ranks.jsp?ST=Medicine&Y=2013. Accessed October 15, 2014.
- D’Silva J.
- Kost A.,
- Chen F.M.
- Maron B.J.,
- Kalra A.
- ↵American College of Cardiology. ACC International Cardiovascular Exchange Database. Available at: http://www.cardiosource.org/ACC/International-Center/Resources-for-You/ACC-International-Cardiovascular-Exchange-Database.aspx. Accessed October 15, 2014.