Cardiology-cardiothoracic subspeciality training in South Africa: a position paper of the South Africa Heart Association

Academic Rank and Productivity Among United States Cardiothoracic Surgeons

BACKGROUND

Despite a significant growth of women trainees in cardiothoracic surgery recently, women remain a minority of cardiothoracic surgeons and hold a minority of leadership positions. This study evaluates differences in cardiothoracic surgeon subspecialty choices, academic rank, and academic productivity between men and women.

METHODS

The Accreditation Council for Graduate Medical Education database was used to identify 78 cardiothoracic surgery academic programs in the United States, including integrated, 4+3, and traditional fellowships, as of June 2020. A total of 1179 faculty members were identified within these programs, 585 adult cardiac surgeons (50%), 386 thoracic surgeons (33%), and 168 congenital surgeons (14%), and other, 40 (3%). Data were collected using institutional websites, ctsnet.org, doximity.com, linkedin.com, and Scopus.

RESULTS

Of the 1179 surgeons, only 9.6% were women. Overall, women composed 6.7% of adult cardiac, 15% of thoracic, and 7.7% of congenital surgeons. Among subspecialties, women represent 4.5% (17 of 376) of full professors and 5% (11 of 195) of division chiefs in cardiothoracic surgery in the United States, have shorter career durations, and lower h-indices compared with men. However, women had similar m-indices, which factors in career length, compared with men in adult cardiac (0.63 vs 0.73), thoracic (0.77 vs 0.90), and congenital (0.67 vs 0.78) surgeons.

CONCLUSIONS

Career duration, including cumulative research productivity, appears to be the most important factors predicting full professor rank, potentially contributing to persistent sex-based disparities in academic cardiothoracic surgery.

Radiation induced cataracts in interventionalists occupationally exposed to ionising radiation

BACKGROUND

Occupational exposure to ionising radiation may have detrimental health effects. Longer and more complex fluoroscopic procedures have placed interventionalists at increased occupational health risks especially for developing cataracts in the radiosensitive lenses of the eyes.

OBJECTIVES

This study aimed to determine the prevalence of occupational related cataracts and describe the risk factors for cataracts in occupationally exposed interventionalists compared with unexposed doctors.

METHOD

A cross-sectional study using multiple methods. A survey was conducted. The radiation workload was determined based on a self-administered questionnaire and dose area product values determined in previous studies. Both groups had slit lamp examinations. The data were analysed analytically using R software version 9.3.

RESULTS

The study included 98 interventionalists. The combined prevalence of posterior sub-capsular (PSC) and cortical cataracts was 18.8% in the exposed and 13.9% in the unexposed group. The prevalence of PSC cataracts in the exposed group was 5.9% and 2.8% in the unexposed group, with an odds ratio (OR) of 2.2 (95% confidence interval [CI]: 0.58; 8.61). Posterior sub-capsular cataracts were more common in the left eye. The increase in cataracts was not statistically significant in the exposed group but is of clinical significance.

CONCLUSION

The findings are important as they highlight the need for greater vigilance for protecting the radiation healthcare workforce in a developing country setting.

CONTRIBUTION

The research is the first of its kind in South Africa and Africa and contributes to determining the prevalence in this highly skilled and occupationally vulnerable group.

Medical education and training within congenital cardiology: current global status and future directions in a post COVID-19 world

Despite enormous strides in our field with respect to patient care, there has been surprisingly limited dialogue on how to train and educate the next generation of congenital cardiologists. This paper reviews the current status of training and evolving developments in medical education pertinent to congenital cardiology. The adoption of competency-based medical education has been lauded as a robust framework for contemporary medical education over the last two decades. However, inconsistencies in frameworks across different jurisdictions remain, and bridging gaps between competency frameworks and clinical practice has proved challenging. Entrustable professional activities have been proposed as a solution, but integration of such activities into busy clinical cardiology practices will present its own challenges. Consequently, this pivot towards a more structured approach to medical education necessitates the widespread availability of appropriately trained medical educationalists, a development that will better inform curriculum development, instructional design, and assessment. Differentiation between superficial and deep learning, the vital role of rich formative feedback and coaching, should guide our trainees to become self-regulated learners, capable of critical reasoning yet retaining an awareness of uncertainty and ambiguity. Furthermore, disruptive innovations such as "technology enhanced learning" may be leveraged to improve education, especially for trainees from low- and middle-income countries. Each of these initiatives will require resources, widespread advocacy and raised awareness, and publication of supporting data, and so it is especially gratifying that Cardiology in the Young has fostered a progressive approach, agreeing to publish one or two articles in each journal issue in this domain.

Found in translation: navigating uncertainty to save a child's heart. Paediatric cardiac surgery in Cape Town, South Africa

This medical humanities paper describes our qualitative research into pathways to care and informed consent for 10 children who had cardiac surgery in the Red Cross War Memorial Children's Hospital, Cape Town, South Africa. Our multidisciplinary team consists of cardiologists, anthropologists, a social scientist and a general practitioner in two sites, South Africa and Australia. This paper builds on our first publication in a specialist cardiology journal on a 'qualitative snapshot' of these children's life stories from 2011 to 2016 but turns to the medical humanities to explore a concept of 'uncertainty'. Data analysis revealed that for the children's parents and doctors, 'uncertainty' underscored procedures. Indeed, the literature review showed that 'uncertainty' is intrinsic to heart surgery and was integral to Barnard's first heart transplant in Cape Town in 1967. We demonstrate that in meeting the challenges inherent in the 'uncertainty dimension', doctors established greater 'medical certainty'about each operation. This happened as they encountered the difficult clinical and biopsychosocial factors that were fundamental to the diagnosis of children's cardiac defects. It was doctors' translation of these decision-making processes that informed parental decisions and described why, despite feelings of uncertainty, parents signed consent. To visually describe heart surgery in this locality we asked the South African photographer, Guy Neveling to record some children undergoing echocardiograms and surgery. These photographs qualitatively demonstrate what medical certainty entails, and parents' trust in doctors and surgeons, whom they knew had 'reasonable certainty' that their child's 'heart is worth saving'.

Realities and challenges for female cardiothoracic surgeons: an African perspective

It is a fact that, despite the worldwide increasing intake of women in medical schools, women are still grossly underrepresented in all medical and surgical specialities, and definitely in cardiothoracic surgery in both developed and developing countries. This is counter-productive towards meeting the escalating need for cardiac surgical care in Africa. However, the natural evolution over time of increasing numbers of females entering medical school and specializing in the field of surgery, is expected to continue despite multiple challenges encountered on their way. The inequities of healthcare provision in Africa in particular needs the continual support of all professionals that are able to contribute to the wellbeing of those innocent individuals that need medical care particularly children born with congenital cardiac defects. In addition to factors on the African continent, realities and challenges for future female cardiothoracic surgeons include gender bias and gender-based discrimination by some male counterparts. The question must be asked: "Is it mere gender-based discrimination, or how much does deliberate 'bullying behaviour' mimic signs of superiority, arrogance and entitlement, bordering on psychological personality disorders?" Thorough investigation of the possible role of such behaviour disorders in gender bias and discrimination is long overdue. These disparities and challenges should be actively addressed on all levels by all role players by placing more emphasis on merit, competence and surgical outcomes than on the gender of the surgeon. Despite all these challenges, the benefits of a career in cardiothoracic surgery and tremendous job satisfaction far exceed the disadvantages.

A Systematic Review of the Spectrum of Cardiac Arrhythmias in Sub-Saharan Africa

Major structural cardiovascular diseases are associated with cardiac arrhythmias, but their full spectrum remains unknown in sub-Saharan Africa (SSA), which we addressed in this systematic review. Atrial fibrillation/atrial flutter (AF/AFL) prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, but <1% in the general population. Use of oral anticoagulation is heterogenous (9-79%) across SSA. The epidemiology of sudden cardiac arrest/death is less characterized in SSA. Cardiopulmonary resuscitation is challenging, owing to low awareness and lack of equipment for life-support. About 18% of SSA countries have no cardiac implantable electronic devices services, leaving hundreds of millions of people without any access to treatment for advanced bradyarrhythmias, and implant rates are more than 200-fold lower than in the western world. Management of tachyarrhythmias is largely non-invasive (about 80% AF/AFL via rate-controlled strategy only), as electrophysiological study and catheter ablation centers are almost non-existent in most countries.

Highlights

- Atrial fibrillation/flutter prevalence is 16-22% in heart failure, 10-28% in rheumatic heart disease, 3-7% in cardiology admissions, and <1% in the general population in sub-Saharan Africa (SSA).- Rates of oral anticoagulation use for CHA2DS2VASC score ≥2 are very diverse (9-79%) across SSA countries.- Data on sudden cardiac arrest are scant in SSA with low cardiopulmonary resuscitation awareness.- Low rates of cardiac implantable electronic devices insertions and rarity of invasive arrhythmia treatment centers are seen in SSA, relative to the high-income countries.

10-year risk for cardiovascular diseases using WHO prediction chart: findings from the civil servants in South-western Nigeria

Background

Globally, cardiovascular diseases (CVDs) have continued to ravage the human existence through the premature deaths of its workforce. Despite this burden, many studies in Nigeria have focused on determining the prevalence of risk factors which alone are insufficient to assess the risk of future cardiovascular events. Therefore, we determined the pattern and predictors of 10-year risk for CVDs in South-western Nigeria.

Methods

We conducted a cross-sectional study among workers at the local government areas (LGAs) of Oyo State. Using a multi-stage sampling technique, we recruited 260 respondents from the LGA secretariats. A pre-tested, interviewer-administered questionnaire was administered to obtain information on the socio-demographics and behavioural attributes. Lipid analysis, anthropometric, blood pressure, fasting blood glucose measurements were done using standard protocols. The respondents’ CVD risk was assessed using WHO prediction chart. Data were analyzed using IBM SPSS version 25; bivariate analysis was done using Chi-square and binary logistic regression was used to identify the predictors of 10-year risk for CVDs at 5% level of significance.

Results

The mean age of respondents was 46.0 + 6.7 years. The proportion of respondents with good knowledge of risk factors was 57.7%. The prevalence of CVD risk factors were as follows: systolic hypertension (29.6%), visceral obesity (35.8%), diabetes mellitus (18.8%), smoking (5.8%), elevated total cholesterol (55.4%) and physical inactivity (84.6%). The proportion of respondents with low, moderate and high risk of developing CVDs within 10 years was 76.9, 8.5 and 14.6% respectively. Respondents with age ≥ 40 years (aOR = 2.6, 95% CI = 1.3–8.5), management cadre (aOR = 3.8, 95% CI = 1.6–9.6), obesity (aOR = 4.8, 95% CI = 1.2–120), abnormal waist circumference (aOR = 2.8, 95% CI = 1.3–5.2) and physical inactivity (aOR = 2.4, 95% CI = 1.2–4.7) were associated with the higher likelihood of developing CVDs.

Conclusion

About one-sixth of the respondents had high risk of developing CVDs within the next 10 years and it is likely that it will reduce the productivity of the State. Lifestyle modification and early detection of risk factors through regular screening programmes for those with high CVD risk is therefore recommended.

Moving Ahead: Building a Strong Network Among Female Cardiovascular Clinician Scientists and Researchers in Africa

This case reports on the authors' successes building a strong network among female cardiovascular clinician scientists and researchers in Africa provides examples of collaborations and mentorship. (Level of Difficulty: Beginner.).

Personal Protective Equipment Availability and Utilization Among Interventionalists

OBJECTIVE

This study explored personal protective equipment (PPE) availability and PPE utilization among interventionalists in the catheterization laboratory, which is a highly contextualized workplace.

METHODS

This is a cross-sectional study using mixed methods. Participants (108) completed a survey. A hyperlink was sent to the participants, or they were asked to complete a paper-based survey. Purposively selected participants (54) were selected for individual (30) or group (six) interviews. The interviews were conducted at conferences, or appointments were made to see the participants. Logistic regression analysis was performed. The qualitative data were analyzed thematically.

RESULTS

Lead glasses were consistently used 10.2% and never used 61.1% of the time. All forms of PPE were inconsistently used by 92.6% of participants. Women were 4.3 times more likely to report that PPE was not available. PPE compliance was related to fit and availability.

CONCLUSIONS

PPE use was inconsistent and not always available. Improving the culture of radiation protection in catheterization laboratories is essential to improve PPE compliance with the aim of protecting patients and operators. This culture of radiation protection must include all those involved including the users of PPE and the administrators and managers who are responsible for supplying sufficient, appropriate, fitting PPE for all workers requiring such protection.

Arrhythmia care in Africa

Data on cardiovascular disease, including arrhythmias, in Africa is limited. However, the burden of cardiovascular disease appears to be on the rise. Recent global data suggests an increase in atrial fibrillation rates despite declining rates of rheumatic heart disease. Atrial fibrillation is also associated with increased mortality in Africa. Current management with medical therapy is sub-optimal and ablation procedures, inaccessible. Atrial fibrillation is also an independent risk factor for death in patients with rheumatic heart disease. Sudden cardiac deaths from ventricular arrhythmias are under-recognized and inadequately treated with very high rates out of hospital cardiac arrest due to poor education of the general public on cardiopulmonary resuscitation skills and lack of essential healthcare infrastructure. Use of cardiac devices such as implantable defibrillators and pacemakers is low with significant regional variations and is almost non-existent in sub-Saharan Africa. There is a great unmet need for arrhythmia diagnosis and management in Africa. Governments and healthcare stakeholders need to include cardiovascular disease as a healthcare priority given the rising burden of disease and associated mortality.

A multiple methods approach: radiation associated cataracts and occupational radiation safety practices in interventionalists in South Africa

Ionising radiation is a modality used in diagnostic and therapeutic medicine. The technology has improved and resulted in lower dose exposure but there has been an escalation in the quantity of procedures, their duration and complexity. These factors have meant increased occupational radiation exposure for interventionalists. Ionising radiation exposure can have detrimental health effects and includes radiation skin burns, various carcinomas, genetic and chromosomal aberrations and cataractogenesis of the lenses of the eye. The lenses of the eye are of the most radiosensitive organs and the risk of cataracts is high despite low radiation dose exposures. The use of personal protective equipment (PPE) is a method that can be used to mitigate the risk for developing lens opacifications. The consistent and effective utilisation of PPE is marred by availability, proper fit and ease of use when performing procedures. Radiation safety training is imperative to enforce a culture of radiation safety among interventionalists. The aim of this study was to quantify and describe cataracts among South African interventionalists and to understand their radiation safety practices. For this purpose, a cross sectional study was designed using multiple methods. A survey was conducted to determine the demographics and the risk factors of doctors exposed to radiation to doctors not exposed. The radiation workload and radiation safety practices of interventionalists were explored. Both groups had slit lamp examinations. The data were analysed analytically and a regression model developed looking at the outcomes and the risk factors. Qualitative in-depth interviews and group interviews were conducted to explore the perceptions of interventionalists regarding radiation safety. Deductive and inductive thematic analysis was done. Interdisciplinary research is challenging but offers tremendous opportunity for exploring and tackling complex issues related to securing a safe radiation work environment.

Perceptions of radiation safety training among interventionalists in South Africa

Exposure to ionising radiation may have deterministic and stochastic health effects, which include skin changes, chromosomal aberrations, cataracts and carcinomas. Formalised training in radiation safety and protection improves knowledge on the subject and facilitates greater compliance in safety practices. This qualitative study included 54 interventionalists (adult and paediatric cardiologists, and interventional radiologists). The participants were purposively selected and interviewed to explore their perceptions about radiation safety. A thematic analysis of the transcripts was done using a deductive and inductive approach. Findings showed participating cardiologists had less knowledge about radiation safety than participating radiologists. Cardiologists reported little or no formal training on radiation safety and did not display a culture of radiation safety. There was no consensus on how the training gap should be addressed. There is a perceived need to change and enhance the radiation safety culture among interventionists, and the participants proffered some ideas. These included the need for re-curricularisation of cardiologists’ training to create awareness of radiation safety practices.

The heart of Africa: succeeding against the odds

South Africa and other areas of sub-Saharan Africa have in the past 20 years undergone rapid demographical changes, largely due to urbanisation and changes in lifestyle. This rapid change has led to a marked increase in specific cardiac conditions, such as hypertensive heart disease and coronary artery disease (with the highest prevalence in the middle-aged population), in conjunction with a range of other heart diseases, which are historically common in Africa-eg, rheumatic heart disease, cardiomyopathies, and unoperated congenital heart disease. The short supply of well-equipped screening facilities, late diagnosis, and inadequate care at primary, secondary, and tertiary levels have led to a large burden of patients with poorly treated heart failure. Excellent progress has been made in the understanding of the epidemiology, sociodemographical factors, effect of urbanisation, and pathophysiology of cardiac conditions, such as peripartum cardiomyopathy, rheumatic heart disease, and tuberculous pericarditis, which are common in sub-Saharan Africa. This progress has been achieved largely through several studies, such as the Heart of Soweto, THESUS, REMEDY, BA-HEF, Abeokuta-HF, and the PAPUCO studies. Studies on the suitable therapeutic management of several heart conditions have also been done or are underway. In this Lecture, I provide a personal perspective on the evolving burden of cardiac disease, as witnessed since my appointment at Chris Hani Baragwanath Hospital, in Soweto, South Africa, in 1992, which was also the year that the referendum to end apartheid in South Africa was held. Subsequently, a network of cardiologists was formed under the umbrella of the Heart of Africa Studies and the Pan African Cardiac Society. Furthermore, I summarise the major gaps in the health-care system dealing with the colliding epidemic of communicable and non-communicable heart diseases, including cardiac diseases common in peripartum women. I also touch on the fantastic opportunities available for doing meaningful research with enthusiastic colleagues and, thereby, having a large effect, despite the need to be highly innovative in finding much needed funding support.