Recently, I had an interesting discussion with a friend and a former colleague about the future of cardiac surgery. My friend now runs one of the largest and busiest cardiac centres in the public sector in the Punjab that is also responsible for training cardiac surgeons as well as cardiologists.

What concerned my friend was that even though ‘competent’ cardiologists are being trained, the number of cardiac surgeons capable of independent cardiac surgery being produced is just not adequate for the expected need over the next decade. Sadly, I am inclined to agree with him.

For more than three decades, I was involved in training cardiac surgeons, first in the United States and then in Pakistan. I served as the professor and chairman of a cardiac surgery department in a public sector university in Lahore for almost seven years. During this time, I was also responsible for training half a dozen candidates for the Fellowship of the College of Physicians and Surgeons of Pakistan (FCPS) in cardiac surgery and in Master of Surgery (MS) in cardiac surgery.

Interestingly, soon after I took over as the head of the department, I realised that my junior ‘consultants’ with ‘fellowships’ in general surgery from UK (FRCS) and local cardiac surgery training needed my help first. Both of them were ‘experts’ under the rules of the Punjab government but, in my opinion, neither were capable of performing ‘safe’ cardiac surgery as independent surgeons. So I had to train these ‘experts’ before I could even think of training my ‘trainees’.

As of today, my former ‘trainees’ that I never really got around to train have all obtained their FCPS and MS qualifications in cardiac surgery and some of them are already serving as consultants in teaching hospitals. But I know that none of them can perform even the commonly done cardiac operations as independent surgeons. Of course, some of them will eventually learn but at what human cost? And that is what my friend was talking about.

Worse, some of these ‘untrained’ cardiac surgeons will in time ascend to positions where they will run departments and even become responsible for training new surgeons. Sadly, like many others in similar positions in the Punjab today they will produce equally ‘inadequate’ surgeons and the game will go on. As I said above, some of them will after ‘trial and error’ and considerable human cost learn how to perform basic surgical cardiac operations reasonably well but that is about it.

Before I go any further, I would like to tell about the difference between surgical training in Pakistan and the US. I performed my first ‘appendix’ operation in Pakistan as a house surgeon in Mayo Hospital in 1971. I was assisted by a student nurse and a medical student. My senior registrar who never asked me about the patient and why he needed the operation said, if you need help, I am in the next operating room. Fortunately, the patient did well.

I performed my first appendix operation in the US a year later. I was assisted by an attending (consultant) surgeon and a fully trained nurse. Before I started the operation, the consultant asked me about the patient, his medical history and all about the reasons why I thought the patient needed the operation. During the operation, the consultant made sure that I did it right, asking me questions along the way about why I did what I did and throughout he was ready to take over the operation if I made a mistake.

Five years later while going through my cardiac surgery training, my senior cardiac surgery consultant helped me through my first coronary bypass operation much the same way, but only after I had assisted him with quite a few bypass operations and he had gauged my surgical ability.

Even though my junior colleagues in Pakistan had never worked with me before, I tried my best to ‘teach’ them as I had been taught. Interestingly, I was the first cardiac surgery ‘consultant’ in local history that actually stood ‘across the table’ and walked a young surgeon through a major cardiac operation! Even if they made a mistake, I was there to take over. Eventually, they were trained well enough that I could sit in the side room of the operating theatre, have a cup of tea or two and let them perform even complicated operations on their own.

Therein lies the difference between the US system of surgical training and the British system that we in Pakistan have inherited and follow most of the time. The British system of training is what I refer to as ‘apprenticeship’, where the teaching concept is ‘watch and learn’. While the US system is based on ‘mentorship’ where the goal is ‘let me teach you how to do it right’.

Both systems produce excellent surgeons. However, the US system is more egalitarian in its approach and the idea is to ensure a uniform and adequate basic level of competence. The British system is elitist where only the very best learn how to do things well. We do have some excellent cardiac surgeons in Pakistan that have come through British or local training programmes, but we just don’t have enough of them to fill all the positions that are available.

Considering the recent expansion of ‘cardiac centres’, this lack of ‘good’ surgeons is unfortunate for three reasons. First, being relatively limited in their own training these senior surgeons are not able to perform complex operations properly. Second, most of the ‘secondary’ centres still train new surgeons and even if we follow the ‘apprenticeship’ method of training, without ‘examples’ to emulate, the trainees will never acquire appropriate skills. Third, being inadequately trained these consultants are not capable of providing leadership in terms of innovation and research that are an important part of the training process.

The other major problem with the Pakistani system of training, as I have seen it, is that by the time most candidates pass their FCPS in cardiac surgery and become ‘certified’ experts, they are already in their middle or late forties. As such, most have little more than a decade left in public service to function as consultants. This sadly has an unfortunate down side. Having spent more than two decades as low paid trainees, once they become consultants their primary goal in life is to earn as much money as they can and as quickly as they can.

So, what needs to be done? First, the training system must be uniform and only the College of Physicians and Surgeons of Pakistan (CPSP) should be responsible for certifying specialists and the college should assure a basic and comparable level of competence for all its qualifying candidates. Second, training should be time limited.

In Pakistan, I will suggest that after MBBS and a house job, cardiac surgical training should be limited to three or four years of general surgery and a maximum of another three years of cardiac surgery. This will let the new consultants to start their lives as consultants early enough to hone their skills and to keep up with the latest techniques and innovations. Also, without going through a formal training programme in cardiac surgery, nobody should be allowed to work as a consultant cardiac surgeon.

We should also develop a system of ‘part time’ consultants. Many well-trained cardiac surgeons are returning to Pakistan after going through excellent training programmes in UK and the US. Most of them prefer to work in the private sector but many of them will be quite willing to participate in the training of young physicians in the major public sector training programmes. It is a shame not to use their expertise.