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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 28, No 5, September/October 2017
296
AFRICA
in another surgical discipline, 91.3% ticked unavailability of
surgical equipment, accounting for the majority (38.7%) that
identified this factor. This can be compared to those who were
still to choose a surgical discipline but were interested in CTS
(28.1%) and those who were already committed to specialising
in CTS (7.8%). Those who considered CTS but would choose
another surgical speciality also formed the majority of those
who identified limited training positions (37% ), poor or lack of
exposure in CTS as a junior resident (38%), and poor or lack of
exposure in CTS in medical school (36%) as factors that reduced
interest in CTS.
Two hundred and eight respondents (87.4%) believed that
making more standard training facilities available in CTS in
Nigeria would bias junior surgical residents towards pursuing
a career in CTS. A large majority also believed that other
important factors that could create a bias towards specialising
in CTS were broadening the scope of training to include open
cardiac cases (71.8%), providing and sponsoring cardiac surgery
training and exposure abroad (81.9%), and providing evidence
of job opportunities that would offer work–life balance (60.9%)
(Fig. 4).
Discussion
This study revealed a lack of interest among junior surgical
residents in Nigeria towards pursing specialisation in CTS. A
study done in the USA showed a declining interest among general
surgery residents in choosing a career in CTS.
3
This is similar to
the experience in the UK where recent studies revealed a decline
in interest in CTS among UK graduates.
4,5
The entry point into a
CTS programme in the West African sub-region is similar to that
of the UK, where the application for entry is made at the level of
PGY-2, unlike in the USA, where most cardiothoracic surgeons
complete an initial general surgery training.
In Nigeria, no institution has been able to maintain and
successfully sustain an open-heart surgery programme, despite a
large number of cases requiring open-heart surgery, especially for
rheumatic and congenital heart diseases.
6-8
In 1974, open-heart
surgery started at the University of Nigeria Teaching Hospital,
Enugu (UNTH) and by 2002, about 102 surgeries had been
recorded.
9
The programme subsequently collapsed but fortunately
it has recently been resuscitated by foreign medical missions.
Falase
et al
. reported 51 cases performed in Lagos State
University Teaching Hospital, Ikeja (LASUTH) between August
2004 and December 2011, with the aid of a mission team. These
cases were done despite gross challenges with support facilities
and inadequately trained supportive staff.
10
It is therefore
understandable that only 13.4% of residents have observed
cardiac surgery, and 2.1% have assisted in open-heart surgeries.
The failure of open-heart surgery programmes in Nigeria has
largely been attributed to heavy financial outlay, intensive labour
requirements and high resource consumption.
6
In addition, the
country has headed from oil boom to oil doom. However in
nearby Ghana, the National Cardiothoracic Centre, Korle-Bu,
reported 464 cases performed annually back in 2008, with 25%
being open-heart procedures, especially surgeries for rheumatic
and congenital heart diseases.
11-13
Unavailability of equipment and lack of training positions
are the key or primary factors that have reduced interest in CTS
in Nigeria. These have ultimately led to the lack of adequately
trained personnel and a fewer number of surgeons practising
this speciality. This has resulted in secondary factors, such as
poor or lack of exposure in CTS as surgical residents and as
medical students. Only 32.2% of residents have therefore done
a CTS posting. A higher percentage (46.2%) appeared to have
undertaken rotations in CTS, as some units combine general
surgery with CTS. Some cardiothoracic specialists also provide
services for more than one institution. More residents are also
likely to have received their undergraduate training in the larger
institutions where there are cardiothoracic programmes.
The role of good exposure in CTS in medical school and in
junior residency cannot be underestimated. A study by Lussiez
et al.
revealed that receiving adequate exposure in cardiothoracic
procedures and disease management was significantly associated
with higher satisfactory ratings in cardiothoracic procedures,
especially thoracostomy incisions, empyema and pleural effusions,
and lung cancer care.
14
Good mentorship and absence of
maltreatment were also positively correlated with good exposure.
14
Good exposure in CTS in medical school may therefore play a role
in biasing residents towards a career in CTS. For instance, Trehan
et al.
revealed that one-third of medical students who received a
0 50 100 150 200 250
Evidence of job opportunities that
offer work–life balance
Availability of more part-time/
flexible work schedules
Access/exposure to positive role
models in the speciality
Evidence of long-term job security
in CTS
Reduced length of training
Subsidising cost of cardiothoracic
procedures
Providing and sponsoring overseas
cardiothoracic surgery...
Broaden scope of training to
include open cardiac surgery cases
Availability of standard training
facilities in the country
Fig. 4.
Graph showing the most important factors that would
bias junior surgical residents towards cardiothoracic
specialisation.
0 50 100 150 200 250
Inadequate remuneration
Long duration of training
Poor or lack of exposure in CTS
rotation in medical school
Poor or lack of exposure in CTS
rotation in junior residency
Personalities of CT surgeons
Limited training opportunities
Unavailability or lack of equipment
to practice as a CT surgeon
Fig. 3.
Graph showing the most important factors that junior
surgical residents believe reduce interest in cardiotho-
racic specialisation.