Forgot your password?
CAN THE UK TRAINING SYSTEM LEARN FROM CANADA?
Interventional Cardiology Fellowship Training in Canada – Can the UK training system learn from Canada?
This article aims to give interventional trainees information on spending time abroad on a fellowship. There are many positives both professionally and personally to living and working abroad.
Step 1. Getting a Fellowship Training Programme in Canada and other places
Fellowship spots can be filled 18 – 24 months in advance, so start doing your research early. Speak to supervisors/mentors or fellow trainees who have done a fellowship abroad, ask for advice and contacts. Having a contact with someone who has been to the centre of interest and can vouch for you, goes a long way, and is often the best way in obtaining a fellowship. Being an unknown is not impossible, but it helps a lot if someone can pick up the phone and say, ‘this is an excellent trainee and you should take them’.
BCIS do have an interventional cardiology fellowship application process but posts are limited and highly competitive. These centres do also take UK trainees outside of the BCIS process and there are multiple Canadian centres that take on fellows. You will be competing with Canadian trainees and other international trainees (typically from Australia/New Zealand and the Middle East who come with government funding, which make them more attractive to Canadian cardiac departments), however UK trainees are well-regarded in Canada, which is an advantage.
What if you have no one who can pick up the phone on your behalf and BCIS is not an option? I’d recommend contacting cath lab directors/fellowship directors directly in Canada. Send them a professional cover letter, your CV and 3 letters of recommendation. This is the standard application process in North America. Essentially, you are ‘cold calling’ centres. You may not get a response from some centres, and some centres may show interest. The Canadian Association of Interventional Cardiology does have a webpage of Fellowship programmes (https://caic-acci.org/fellows/). At the time of writing only the McGill University contact is incorrect. Meeting prospective Fellowship Directors from Canadian centres at conferences such as ESC, TCT and ACC is an opportunity to impress. So be persistent.
The glamour locations in Canada are Toronto, Vancouver, and Montreal (ideally need to be able to speak French). However, some of these centres are lower volume. Centres such as Edmonton, Hamilton, Calgary, Winnipeg, Halifax are higher volume in PCI with surrounding natural beauty and the big city element, so there is something for everyone and with cheaper living costs.
The other point to consider is funding, some posts are paid (Ranging from $50,000 to $75,000 CAD/year, commonly most centres pay $60,000 CAD/year) whilst others are unpaid. There is sometimes an opportunity to cover the Cardiology service (essentially reg on call) and get paid locum rates which can help boost your income. Plan your finances accordingly and start saving early during your UK training as the cost of living in Canada is more expensive than the U.K., in particular rent, food, and car insurance. If you can obtain sponsorship or grant money of some sort then great, so use your professional contacts for advice. Unpaid fellowships will require one to have extremely deep pockets. Other financial costs to factor in are immigration paperwork, flights, licence applications, and medical examination (including Chest X-ray). Also budget for holidays whilst in Canada, as you will want to make the most of Canada’s natural beauty.
Step 2: Fellowship Experience
You will need to decide how long a fellowship you need, either one-year or two-year? What skills would you like to focus on, CTO or structural? Traditionally, PCI training in Canada was just one year, similar to the USA. There has been a real change over the last ten years for 2-year fellowships. For Canadian trainees, following completion of General Cardiology training in Canada (3 years), those wishing to sub-specialise will undertake a 2-year programme in Interventional Cardiology. Most centres now have Royal College of Physicians and Surgeons of Canada approval for the Area of Focused Competence (AFC) programme. This is a 2-year programme setting out the pathway for CCT equivalence in Interventional Cardiology. There is a drive in Canada for all Interventional Cardiologists to achieve this diploma which is competency based and requires trainees to maintain a logbook and show evidence of competence achievement through workplace-based assessments, similar to the NHS eportfolio. The advantage I had in my programme, our fellowship coordinator would send all our assessments to the staff, whose responsibility it was fill in the assessments and send back, this included mini-CEX, CBDs and MSF equivalents. On top of this, every 6 months we would have a summative assessment which involved an OSCE and MCQ exam. You will have access to the SCAI and CRF fellows’ courses, with the majority paid via industry.
A two-year programme has 2 phases, year one is achieving competency in most aspects of PCI; approximately 500-600 PCIs will be achieved. Year 2 may have a focus on either CTO, TAVI, Mitraclip where competency will be achieved, or exposure to structural interventions with competency in complex PCIs (LMS, Rotablation, Bifurcation 2-stent strategies, Mechanical Circulatory Support, AWE CTO) and dedicated research time. The aim of the 2-year programme is to be an independent Complex PCI Operator. You will expect to achieve over a 1000 PCIs, if not more, over a 2-year programme. Some one-year programmes that are tailored for trainees with prior experience can achieve 600-1000 PCIs in one year. So again, do your research, as a UK trainee you likely will have already completed PCI training, you may decide I need more PCI volume, or complex PCI experience. Therefore, you may just want a one-year fellowship or you may want to do 2 years, where you could do PCI in the first year and structural in the second year, either TAVI or Mitraclip. Finally, you may wish to stay for a second fellowship, and as you are already in Canada, opportunities for further fellowships do open up.
What is the actual fellowship like compared to the UK?
There is a genuine focus on training with little or no service provision. Service provision is minimized at all levels of training in Canada. In terms of the working day, it is usually from 7am – 6pm; you will likely perform 8-10 cases a day, turnaround times are quicker compared to NHS centres. Some centres work longer, until the ‘slate is clean’, i.e., all the acute cases (NSTEMIs) are done until the list is finished, which could go on until midnight! You may be in the lab 3-5 days a week, with research days in between. During my PCI Fellowship, I had no ward commitment and one PCI clinic (6-8 patients) every 3-4 weeks. My on-calls were for STEMI only, usually a 1 in 3 on-call, sometimes 1 in 2. In Canada, the consultants take the STEMI calls, so my role was to turn up to the cath lab, consent the patient and perform the PPCI. The majority of the paperwork is completed by the Staff (Consultant).
Training attitudes in Canada are different compared to the UK. I’ve observed that Canadian trainees start their PCI training at a lower baseline compared to UK trainees but by the end of year one have achieved more PCI than UK counterparts. There is a real focus on training and allowing the trainee time and space to learn, make mistakes and grow. Trainees are treated as colleagues; first names are often used and there is a real relaxed manner to the workplace. Hierarchical structures to healthcare, that are commonplace in the NHS, are minimised in Canada, which brings a more cohesive atmosphere. The attitude amongst trainers is positive, we will get you there and everyone is trainable. We had weekly PCI rounds, where interesting cases were discussed, complex cases discussed regarding strategy, and each fellow took turns to present a topic. Once a month, we would go through complications and discuss these cases in a non-judgmental manner.
I also had an option to take an elective and work in another province for a month. Usually this is done for networking purposes, to work at a centre you may want to work in the future and gives a chance for you and the team to get to know each other or be exposed to another operator with a specific skillset. This was a great opportunity for me to work with a nationally renowned CTO operator and work in the busiest PCI programme in the country. Seeing how efficiently their cath lab operated was eye-opening. Which brings me on to my next point. Working in a different health care system has given me the skills and experience to implement positive changes when I become a consultant.
From a personal perspective, Canada is a great place to live. Canadians are super-friendly and helpful. My family moved to Canada with me, and the experience has been very positive for them also, making the most of the opportunities available – my kids are now proficient skiiers and skaters, and they enjoy being active in the community football leagues. We travelled to the Rockies regularly and made excellent use of our local ski hill. If you wrap up appropriately you can get through the winter and the summers are fantastic.
What can the UK training system learn?
The UK training system has undergone a big change recently with Shape of Training. It appears inevitable that post-CCT fellowships will be required for Interventional Cardiologists, which may require a further 2 years, especially if you are interested in CTO or Structural Intervention.
The UK has excellent high-volume centres with high-calibre trainers and access to all available technologies, compared to some Canadian centres which do not have access to all the latest gadgets and some centres have low-uptake of intra-coronary imaging and pressure wire assessment. The key difference between Canada and UK is the consistency that trainees have in terms of their access to the Cath lab; trainees are consistently timetabled, with no other distractions such as ward work and ward weeks, no post-on call days off, no general cardiology on-call and clinics are minimized.
Potential solutions for UK training centres include dedicated PCI modules for trainees where no other commitments are scheduled for a period of 3-6 months in ST6/7 years. On-call rotas could be re-structured where PCI trainees are on-call for STEMIs only, although of course this would have implications for compliance with the European Working Time Directive. Implementing electives in centres you may wish to work in would be helpful, as this would give both sides an opportunity to get to know each other or if there was a specific skill set you were interested in. However, these solutions could be unpalatable to non-PCI trainees, who might have to do a higher percentage of general cardiology on-calls. Finally, as my Canadian programme director mentioned to me once, ‘family comes first’, UK training programmes need to show more flexibility and be more holistic to support all trainees, especially working parents. There is a BCIS focus group looking at training culture and improving this. Despite doing more on-calls and having more Cath lab time compared to the UK system, I felt more refreshed and energetic.
While I have concentrated on Canada given my own experience there, similar processes can be found in other overseas centres, for example in Australia and New Zealand. All these countries have the major advantage of having English as the first language for most people. Of course, there are many trainees who for family or other reasons cannot go abroad and excellent opportunities also exist in the UK.
To summarise, research early, decide what are your main objectives from doing a fellowship, make contact, make a financial plan, and enjoy the fellowship!