Cardiovascular Journal of Africa: Vol 27 No 3 (May/June 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 3, May/June 2016 AFRICA 191
among secondary and primary-level institutions. The inadequate
number of public service paediatric cardiologists affects training
and outreach programmes to our neighbouring provinces and
countries.
Several novel approaches have been attempted to remedy this.
The Walter Sisulu Centre of Africa previously attempted to fill this
gap, the African Paediatric Fellowship Programme (APFP, http://
serves to train paediatricians
from across Africa, including paediatric cardiologists and surgeons,
and collaborations between countries such as South Africa and
Ethiopia have used task shifting to build capacity.23 Paediatric
cardiac services in several provinces, such as Limpopo, rest on
the shoulders of paediatricians with an interest in paediatric
cardiology in order to diagnose patients, refer timeously and
continue post-operative management and treatment.
Cardiothoracic surgery training in South Africa
Currently, training in cardiothoracic surgery requires entry
into a four-year programme post qualification. The four-year
training programme encompasses a three-part examination in
General Surgical Principles Part I, Intensive Care Principles
Part II and Cardiothoracic Surgical Adult and Congenital
Surgery Part III. Entry into the discipline is dictated by a single
exit examination, which can be sat after acquiring Part I and
II. The exit examination needs to be supported by a case load
report, verified by the head of department prior to, or at the
time of, sitting the Part III examination. Further requirements
are competency in the practice of cardiothoracic surgery, which
needs to be evaluated and confirmed by the head of department
where the individual has undergone training.
To enable the country to satisfy its need for surgeons in the
discipline, there are currently seven academic departments with
a staff compliment of 28. Currently there are 21 surgeons-in-
training at various residency levels.
The number of registered cardiothoracic surgeons in the
country is 103. The need for cardiothoracic surgical expertise is
estimated to be one surgeon per 800 000 population. Currently,
the number of surgeons per population equals one per 4.5 million.
Furthermore, there is an unequal distribution of surgeons
servicing the private sector, as opposed to those servicing the
public sector where the greatest need for service delivery exists.
In order to equalise or rectify this discrepancy, there needs to be
ongoing political involvement in equalisation of remuneration.
The current College of Cardiothoracic Surgeons of the
College of Medicine of South Africa is in the process of
reviewing the training period and instituting a recommendation
and requirements for the training period to be extended to a total
of six years.
The Society of Cardiothoracic Surgeons of South Africa is
involved in coordinating additional training of residents by having
established a Residents’ Forum in 2000. This Residents’ Forum
has now been embellished by the involvement of the European
Association of Cardiothoracic Surgeons education programme,
which has contributed to this meeting in the past years. The
Society is also currently involved in establishing an exchange
programme between the Israeli Society and the South African
Society, whereby a number of registrars and/or consultants will
be exchanged on an annual basis in order to further enhance the
training of South African surgeons and vice versa.
The subspeciality of cardiac electrophysiology
The subspeciality of cardiac electrophysiology (EP) and pacing
has become one of the more popular subspecialities in cardiology
worldwide. However, EP in South Africa and SSA has long been
considered to be a ‘niche’ subspeciality. Over the past 20 years,
Groote Schuur Hospital in Cape Town has attracted several
full-time EPs, and currently has the only full-time academic
EP in South Africa. Fortunately, there are two part-time EPs
performing sessions at Chris Hani Baragwanath Hospital in
Johannesburg and Albert Luthuli Hospital and Grey’s Hospital
in Durban and Pietermaritzburg, respectively.
The legacy of having a full-time EP service at Groote Schuur
Hospital has stimulated interest in the field and has led to a
further seven Groote Schuur Hospital cardiology registrars
subspecialising in EP, mostly in North America and Europe, over
the past 10 years. No training post for an aspiring EP exists in
South Africa and all will need to perform an overseas fellowship
(usually two years in duration). There are currently 13 CASSA-
accredited EPs registered in South Africa, with a rough estimate
of one EP per 21 million people in the public sector, compared
to one EP per 800 000 people in the private sector.
It is not surprising that EP does not form a significant part of
the core cardiology curriculum of cardiology training in South
Africa. Cardiology registrars need to observe 15 EP cases to
complete the logbook for the certificate in cardiology. This is
inadequate to teach and understand the principles and practices
of EP and does little to stimulate interest in the field. Most of
the cardiology registrars outside of Cape Town observe cases in
private hospitals around South Africa.
Cardiac pacing for bradyarrhythmias is considered a
core skill in the training of cardiologists in South Africa.
Cardiology registrars need to implant a minimum of 30 cardiac
pacemakers (including five dual-chamber pacemakers) before
being considered for the written and oral examination. The
practical training of cardiac pacing at academic institutions is
highly variable and mostly taught by general cardiologists. Many
institutions are dependent on industry for device interrogation
and troubleshooting.
The current implantation rate in South Africa is 60 per
million people, which is much lower compared to European
countries such as Germany, where the implantation rate is much
higher. There is still a lack of cardiac pacing in four out of 11
provinces in South Africa. There is also a severe shortage of
pacemaker implanters in the rest of SSA. In order to address
this urgent need for cardiac pacing, the PASCAR Fellowship
in Cardiac Pacing has been established. Doctors will be able to
learn the principles and practices of cardiac pacing at Groote
Schuur Hospital for a six-month period – the first fellow started
in March 2016.
Implantable cardioverter defibrillators (ICDs) and
biventricular pacemakers are limited in most academic
institutions because of financial constraints and a lack of skilled
expertise to implant them. Cardiology fellows need to observe
10 ICD and 10 biventricular implants for the logbook. Further
additional training is often needed before cardiologists feel
competent to implant them. CASSA has identified the need to
improve the management and implantation of ICDs and has
proposed an additional accreditation examination for non-EPs.
Currently, all aspiring electrophysiologists need to seek overseas
training, usually in North America or Europe. Compared to