By Payal Kohli, MD

As a welcome break from the long chronic total occlusions in the San Francisco VA cath lab, I decided to use the last vacation block of my first year to tour two of the most beautiful countries in Europe that I had always heard so much about—Switzerland and Spain. My European adventure turned out to be so much more than just an immersion in the Swiss and Spanish culture, food, and music. It turned out to be a real journey of discovery of the world of international cardiology and the challenges that face our colleagues abroad.

First on my Europe itinerary was a trip to Zurich, which was complete with a tour of the University of Zurich Cardiology Division, headed by European Heart Journal Editor-in-Chief Thomas Lüscher, MD. The hospital itself was immaculate, with artwork around every corner. It was exactly like an American hospital, except with more character and charm. Only after leaving the hospital and spending some time with my Swiss friends did I discover the differences that hid beneath the surface.

Cultural Differences Necessitate Different Approaches

My next 3 days in Zurich, Bern, and the Swiss countryside were so full of large meals with Swiss cheeses, breads, meats, and wine that I couldn't help asking my friend, who is himself a physician, why atorvastatin wasn't also served with the meals. Although the portion sizes could not rival American portion sizes, I ate food full of saturated fat and carbohydrates from the moment I opened my eyes (cheese, croissants, and whole milk for breakfast) until the very last bite of dessert (Swiss meringue made with cream and sugar). I was mocked by my Swiss friends when I asked them for skim milk or asked where their gym was. "It's important to eat well and live life to the fullest," they retorted.

On my last day in Switzerland, I stuffed my small suitcase full of the fancy cheeses I was bringing back for gifts and reflected on all that I had done (and eaten!). I realized that being a Swiss cardiologist was, in some ways, a lot harder than being an American one. Because of the obesity epidemic, the American diet has come under intense scrutiny and there is tremendous awareness amongst Americans regarding diet, exercise, and avoiding smoking that doesn't seem to exist to the same degree in other countries.

I left Switzerland for Spain with these thoughts (and a few extra pounds), wondering if Madrid might be different. I was staying with a lovely friend, Carolina Granda Nistal, MD, who is a currently an interventional cardiology fellow. Together we visited her hospital and spent the afternoon indulging in tapas at the outdoor café across the street, the local hangout for the residents and fellows there. We were surrounded by young physicians from every discipline, who were savoring their fried and fatty foods in a meal that lasted more than 3 hours.

We were also enveloped by a thick cloud of cigarette smoke that I found oppressive on so many levels: not only did it make it hard to breathe, but it also gave me a lump in my throat that I couldn't seem to get rid of. How could these young doctors possibly counsel their patients about the health hazards of smoking when eating rich food and smoking cigarettes were such an important part of their traditions and culture?

Can We Truly Practice 'Global Cardiology'?

My Spanish counterpart and her colleague, Beatriz Garcia-Dominguez, MD, spent the next 3 days serving as my tour guides around Madrid and Toledo. Along our long walks through the city center and small Spanish villages, they educated me on the medical training system in Spain.

At the age of 18, all students take an exam that determines placement in medical school; undergraduate training is skipped altogether. This training is paid for almost entirely by the Spanish government. Following 6 years of debt-free medical training, which includes pre-clinical and clinical work, they then select a subspecialty (i.e., cardiology) and spend 5 years of clinical immersion training, which includes doing more than 500 echocardiograms (there are no sonographers or technicians) and more than 350 cardiac catheterizations alone.

There is no need for COCATS numbers in Spain because, with 5 years of full clinical training, their volumes are incredibly high and unparalleled by the 3-year fellowships in America. If they were here, they would have Level 3 certifications in everything!

Following this "residency" in cardiology, they can then pursue additional advanced training in subspecialties, such as interventional cardiology, which are usually the same length as US advanced training fellowships (although their work hours are much better). This gives them license to practice anywhere in Europe.

I couldn't help but wonder that maybe the Europeans have medical training figured out much better than we Americans. At the age of 30, the average Spanish cardiologist is fully trained and has received much more focused, intensive, and in-depth training than an American cardiologist, who is still probably a first or second-year cardiology fellow at that age. Are we wasting our time doing undergraduate training and long internal medicine residencies when we hardly use a fraction of what we learned in college or maintain our internal medicine board certifications?

Maybe we could shrink our medical training if we emulated the European model. Perhaps the introduction of more 6-year medical training programs (which are uncommon in most medical schools) would help, or perhaps more "short-tracking" during internal medicine residencies for those becoming subspecialists would allow for more time for clinical training (not research as we currently have for short trackers).

In his opening lecture at ACC.13, Valentin Fuster, MD, discussed the challenge of global cardiology. Although he was referring to global cardiology in another context, I left Europe realizing that global cardiology truly presents a real conundrum. Can we really practice global CVD prevention through lifestyle modification, while at the same time respecting individual preferences and century-old cultural traditions?

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Payal Kohli, MD, graduated from MIT and received her MD from Harvard Medical School. She completed her internal medicine residency at Brigham and Women's Hospital in Boston and was a research fellow at the TIMI Study Group. Dr. Kohli is now a clinical fellow at the University of California, San Francisco.

Keywords: Internship and Residency, Fellowships and Scholarships, Government, Meals, Life Style, Schools, Medical, Europe, Internal Medicine, Certification, Awareness

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