Cardiology and Cardiothoracic Surgery

Disclaimer
The information below may be or may be not accurate. Do not use it as reference. It’s only to give a rough picture on what’ going on with the cardio world in Malaysia from observations of a mere medical student. Some corrections are needed.

This article has been published previously in NNSMA website. Due to inactivity of the website, I had to move the article to my blog with some touch-ups.

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I asked a random question to medical students here and elsewhere: what kinda specialty are you interested in? Fair enough, half answered “physician” and the other half answered “surgeon”. But most who are interested in surgical field choose cardiothoracic surgery. Neurosurgery follows next. I don’t know what’s so special about being a cardiothoracic surgeon. So you can operate on a heart. So what?

And those who answered “physician” want to be cardiologist!~ Fine! Heart is one of the most important organ. But why heart?

I’ve got some inputs from my observations during my elective posting in Institut Jantung Negara; about the life and career of cardiologists and cardiothoracic surgeons (read: CTS). This is not a generalization of other cardiologists and cardiothoracics people in Malaysia.

Okay after we graduate from this hellhole (don’t flame me arrr), we become House Officers (HO) for 2 years. Then we become medical officers (MO) for approximately 3 years. After these 4-5 years of being HOMO, we usually can specialize in a specific medical/surgical area, depending on our performances as doctors.

CARDIOLOGIST

To become a cardiologist in Malaysia, after those miserable 4-5 years of being HOMO, one will pursue further studies under several cardiologists at a particular university hospital. Locals go for UM, UKM, USM etc, overseas opt for MRCP in the UK or American Cardiology Fellowship or its similar Australian counterpart. The course usually takes 3-4 years. During this period of specialization you are called registrar or fellow.

After graduating the cardiology course, passing necessary exams, you’ll have to work at a hospital. Your title is now a senior registrar (read: SR). During my posting in IJN, I worked with a senior registrar. He looks young, late 20s or early 30s. But actually when I asked nurse, his age is 34! See how long you can be a junior specialist in cardiology? 5 years of HOMO and 4 years specialization. 9 long years!

Well, that is only senior registrar. They’re specialists, but they are not consultants. To become a consultant, you have to pass certain exams to upgrade oneself to become consultant. SR usually works for several years before eligible for examination to become a consultant.

Basically in the mornings are ward rounds, then clinic till late afternoon. If there are medical discussions or Mortality and Morbidity conference (M&M), the cardiologists engage in them. One special day for heart failure and cardiac angiogram for each cardiologist. At free times, eat, go back to room, do research. My best hours during attachment in cardiology were in the clinic where at only a medical student level, I could learn important signs and symptoms, principles of drugs prescriptions, listening to heart murmurs etc etc.

CARDIOTHORACIC SURGEON (CTS)

Ok, we got thru medical school and 5 years of HOMO (Housemanship and MOship). Then we specialize in General Surgery. The specialization takes another 4 years. So only 9 years after med school you can get full gazettement as a general surgeon. Then serve 2 years under the government. General Surgeon is not a cardiothoracic surgeon (CTS) yet. To become a CTS of IJN, one will have to spend 6 years as SR (senior registrar) in Institut Jantung Negara. So before one can start becoming a CTS in Malaysia, one has to wait for 11 years.

First year SR basically did almost nothing of importance as a CTS, except case reports and holding retractors or suctions during surgery. At third year of SR, one gets to cut the the chest open, including sternotomy. To put a heart on bypass machine (extracorporeal circulation), a more senior SR is needed. Probably those in 5th or 6th year. After the 6th year of training, you’re already experienced to do relatively simple heart surgeries. Note the word simple.

After 6th year of SR, one becomes consultant. But even consultants can’t operate on everything. Some of them are qualified/licensed by the head of department of CTS to do more complicated heart surgeries. Some procedures are very complicated that not all CTS can do. I saw a senior consultant who’s at his late 40s couldn’t do a complicated surgery (Bentall Procedure, Hemiarch replacement = to replace dissected thoracic aorta). He has to be lead by the head of department, who did the procedure excellently!

Coronary Artery Bypass Graft (CABG @ Cabbage @ Bypass) make the most of the surgeries. Then followed by valve surgeries. But there’s superbly rare case of congenital heart disease is truncus arteriosus. If you watch Grey’s Anatomy, there’s one part when Burke asked the interns on truncus arteriosus before they can scrub in in his surgery. Only Christina could answer, but Meredith and Alex couldn’t, but at that time, Burke and Christina were not talking to each other.

Well, in IJN and in whole Malaysia, only one CTS can do the truncus arteriosus correction; the head of department of CTS. The case is so rare that happens only once per ten thousand of birth (needs checking please), but since IJN is only the place where truncus arteriosus correction can be conducted, I’ve seen two of this particular case.

So, even when you’re at your 40s, not all heart operations you can do! Some are so complicated that you have to give up the “hero” title to more senior consultant CTS. Don’t expect you can cut so much thing when you’re a surgeon. Remember, the first year you’re CTS, you only get to write case reports and assisting insignificantly. That is in IJN.

So, people, still wanna specialize in HEART?