Nov 3, 2015 | Fernando Iñarra Talboy, MD
International

Nowadays, with global access to information and data sharing, almost all academic activities can be performed the same way regardless of the physical location of the people involved. In medicine, this is partially true. We can read the same papers and access the same books almost anywhere on the globe. However, we cannot receive clinical training through a computer, so an old saying in medicine is still valid: “The best book is the patient itself”.

Keeping in mind the importance of clinical training for cardiology fellows, external rotations complementing different programs should be sought, whether local or international. The ACC FIT International corner may provide a very important link between different training programs around the globe, allowing international FITs to choose external clinical rotations to supplement any program.

For any Spanish-speaking FITs, Mexico provides excellent clinical training opportunities. The Mexican health system is divided into four main sectors: federal and local health secretaries, social security, social security for government workers (government dependencies, oil workers and the military) and the private sector. Each sector has cardiology training programs with pros and cons.

Each of these health services is divided into three levels: the first level corresponds to general and family practitioners; the second level to general hospitals; and the third level to high specialty medical attention.

In order to become a cardiologist in Mexico, every doctor is required to complete at least two years of internal medicine (in Mexico, internal medicine lasts four years), to then enter a three year cardiology training program.

I am currently receiving my cardiology training in one of the most important centers in the country, the National Institute of Cardiology “Ignacio Chávez,” in Mexico City, which is a third level institute dedicated to medical and surgical care of cardiac patients, research and teaching. All of the complex, and not-so-complex cardiac patients that require specialized attention, from all around the country are concentrated here, many of which do not have any medical insurance or social security. This may appear to be a disadvantage in the health system , but provides a unique training opportunity.

Despite having every cardiology subspecialty and technological aid available, such as cardiac imaging, echocardiography, interventional cardiology, electrophysiology, cardiac surgery and cardiac rehabilitation, we are taught to build and rely on strong clinical skills. For example, whenever an outpatient is admitted for the first time, the residents are required to perform a complete history and physical exam, and have to make a presumptive diagnosis only with the aid of a 12-lead electrocardiogram (ECG) . We are not allowed even a chest X-Ray in our presumptive diagnosis. This becomes the routine for every first and second year resident, every week, so it will be only a matter of time before their clinical skills are perfected.

Without noticing, you are able to ask better questions (keep in mind that the majority of our patients have completed elementary school at best), you inspect better, you learn to palpate better and you start to listen for things with your stethoscope that you may not have noticed before. You learn to make a detailed analysis of a 12-lead ECG.

In two weeks or so, the patient you saw for the first time, returns for the first follow up visit, with laboratory studies and X-Rays (yes, we still use left and right anterior oblique projections), and you receive clinical feedback from an experienced clinical cardiologist. Many of our teachers are true master clinicians, who have been practicing cardiology for many years, many of them before there were even echocardiograms, who have made diagnoses relying on the auscultation alone, and with the aid of a phonocardiogram, an X ray and an ECG.

This may seem time consuming and not so efficient, but with time you notice that you are able to perform very accurate clinical diagnoses, from congenital heart disease (very common in our hospitals), valve heart disease (degenerative and rheumatic), arrhythmias and cardiomyopathies.

Annually, over 50,000 outpatient consults are given, around 7,000 emergency consults and more than 6,000 hospitalizations. Approximately 47 percent of these patients have congenital heart disease, 40 percent ischemic heart disease, 9 percent valvular heart disease, 3 percent cardiomyopathies and 1 percent cardiopulmonary diseases, mainly pulmonary arterial hypertension.

Despite all these advantages, there are a few drawbacks as well. The most important is that there are no “non-cardiac” patients; there are no consults for any medical or surgical patients who do not have any primary cardiac problem, such as preoperative evaluations, pre-chemotherapy consults, preventive cardiology services or sports medicine.

In comparing the training program between my institution and other cardiology centers in Mexico, there are many similarities. Both the social security system and the government social security have third level cardiology centers around the country, where cardiac patients are concentrated. In some of these centers the main difference in training is that there is more “hands on” training, where the cardiology resident is required to perform more procedures up to and including diagnostic coronary angiographies in some cases.

In this new era of medical training, where student mobility should be encouraged, I think Mexico provides excellent training sites that can complement the needs of any international FIT who wishes to have international clinical experience, providing the best of two worlds: the clinical skills and the technology.

By Fernando Iñarra Talboy, MD, a fellow in training in ACC's Mexico Chapter.