This week we review a report from the teams at University College, Dublin and Texas Children’s Hospital about a collaborative approach to education in which two centers across the globe participate in a shared fellow learning conference. In this conference which is aimed at fellow education, topics are chosen and discussed with facilitated learning from faculty at both sites. What can be gained for fellows on opposite sides of the Atlantic that cannot be learned from exposure to just their one site? How did this approach help fellows learn about how to deal with uncertainty in decision making? How did this trans-continental learning approach enhance patient and team communication? These are amongst the many questions posed to senior cardiologist and senior author of this week’s work, Professor Colin McMahon of University College, Dublin, Ireland.
· DOI: 10.1007/s00246-024-03469-x
· DOI: 10.1007/s00246-024-03469-x
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Speaker 1 (00:16):
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai, where I'm also the Chief of Pediatric Cardiology.
Thank you for joining me for this three hundred and
thirty second episode of Pdheart. I hope all enjoyed last
week's co branded episode with the SADS Foundation, in which
we spoke to doctor Charles Barrul about exciting new technologies
(00:39):
for pacing in children and those with congenital heart disease.
For those of you interested in electrophysiology, I'd certainly recommend
you take to listen to last week's three hundred and
thirty first episode. As I say most weeks, if you'd
like to get in touch with me, my email is
easy to remember. It's pdheart at gmail dot com. This
week we move on to the world of fellow education
(01:00):
in cardiology. The title of the work we'll be reviewing
is Twinning International Pediatric Cardiology Fellowship Programs, a transformative education
experience for trainees with potential for global adoption. The first
author of this work is Sean Kelleher and the senior author,
Colin McMahon, and the authors come to us from the
Department of Pediatric Cardiology at Children's Health Ireland at Crumlin, Dublin, Ireland,
(01:24):
the Department of Pediatric Cardiology at Texas Children's Hospital in Houston, Texas,
UCD School of Medicine in Bellfield, Dublin in Ireland, and
finally Mastrict School of Health Professions Education in Mastrik, the Netherlands.
When we're done reviewing this paper, I'm thrilled to mention
that the senior author, doctor McMahon will be speaking with
us all the way from Dublin. Therefore, let's move straight
(01:45):
on to this article and then a conversation with its
senior author. This week's work begins with a few comments
about a novel educational partnership that was created between the
Cardiology fellowship programs at Texas Children's Hospital and Children's Health
in Dublin, Ireland. The authors mention that since the COVID
nineteen pandemic, they have observed that there has been, to
use their words, an unprecedented willingness to embrace online learning formats,
(02:09):
and they suggest that webinars are one such example, and
I might add one might say that podcasts are a
similarly accepted format. The authors explain that webinars allow for
improved attendance to conferences, and they posit that they may
enhance what they refer to as deep learning. The authors
explain that the partnership between the Dublin and Houston programs
essentially was an alternate monthly conference in which there was
(02:32):
a didactic lecture or a case presentation. Both were usually
presented by a fellow at one of the two centers,
followed by a discussion that was chaired by experienced facilitators,
and eventually followed by a question and answer session. The
authors then define what they mean by the term twinning
used in the work's title, and they explain that this
is a collaborative model whereby two communities partner to share resources, knowledge,
(02:55):
and staffing to achieve a common goal, and they describe
this concept charding with the European Union, in which member
countries work together to achieve goals. They then reference prior
works showing that it was demonstrated to have benefit in
low income countries. The investigators then explained that the partnership
between Texas Childrens and the Dublin Group developed over a
four year period, and there's a table Table one on
(03:18):
page five hundred and eighty one that shows the differences
between the programs, and I'll just mention a few of
the highlights. For example, there are three surgeons in Dublin
versus eight in Houston. There's a total of fourteen pediatric
cardiologists between the member Irish programs at Crumlin and Royal
Belfast Hospital, but sixty eight at Texas Children's. Texas has
(03:39):
seven categorical fellows per year and seven subspecialty ones, and
Dublin has one to two categorical fellows with one additional pediatrician,
meaning that the Dublin program has a total of about
six fellows and Texas about twenty. The Dublin program performs
roughly four hundred and fifty surgeries annually and the Houston
program one thousand in one hundred and fifty, with six
(04:01):
hundred and fifty or so catheterizations in Dublin and fourteen
hundred and fifty in Houston. For those interested in other
differences between these programs, I would, as usual recommend it
all go to the paper and read some of the
fascinating differences, and the link to the paper will be
in the show notes. Despite these differences, the authors explained
that the two very different institutions share a number of
(04:22):
critically important goals, including providing excellent care to infants and
children with congenital heart disease and acquired heart disease, and
the development of a bridge or collaboration between two internationally
respected and known centers, which seem to have been built
in part due to a relationship between doctor McMahon in
Ireland and doctors Penny and Allen and Texas Children. And
(04:42):
for sure, I'm sure we will all want to hear
how this actually got started. The authors explain that the
desired competency of the Fellows as broad medical knowledge, technical mastery,
particularly an echo, and also increasing emphasis on excellent communication
and challenging situations. They explained that the were also trying
to encourage critical thinking in a specialty where we often
(05:03):
don't have large clinical trials upon which to base decisions,
and how to make these sorts of decisions in the
absence of this sort of hard data, while also emphasizing
how the two centers come to different decisions, sometimes about
the same case. With this as a background, the authors
explained that the goal of the study was to evaluate
the utility of the program as perceived by the trainees
(05:24):
in both centers, using both quantitative and qualitative measures, with
a secondary aim of learning more about pediatric cardiology fellows
perception of training in the field and the difficulties that
are encountered. The authors basically had the fellows answer a
questionnaire which was offered via email, and the questions asked
were both closed ended ones and open ended. The questions
(05:45):
asked are reviewed in the paper and the methodology used
by the authors is of interest and perhaps beyond the
scope of a podcast, but suffice it to say that
they used standard open and closed question techniques to assess
answers to the survey and on to the results. All
the authors explained that six of the Irish Fellows and
twenty of the Texas Children Fellows were invited to participate,
(06:06):
and in total, fourteen fellows or fifty four percent of
those who were asked to participate, actually did. Seventy one
percent of the fellows or ten were from the Texas program,
while the remaining four were from Ireland. And so perhaps
one of the most important questions, did the fellows actually
find these conferences helpful? And the answer was that ninety
three percent answered that they did, with the remaining seven
(06:29):
percent answering in neutral. The topics reviewed are listed in
the report, but the most highly ranked session was a
management case of VSDs and how management differed between the
United States and Ireland, and the second highest ranked session
was management of aortica trisia with VSD with normal biventricular dimensions.
(06:49):
The majority, or seventy one percent of the respondents felt
that the sessions highlighted areas of clinical uncertainty in practice
and spoke about how different the practices were in the
different locales in regard to difficulties or areas for improvement.
I think that most listening would not be surprised to
learn that finding time for participation and attending was a
major concern for the fellows, with fifty percent stating that
(07:11):
it was hard to find time to do this and
the reason for this in most cases was significant clinical responsibility.
About twenty nine percent or about a third, were able
to generate a research question from participation, and the majority
of the participants thought that extending this to other centers
would even improve upon the learning experience. Interestingly, when fellows
were asked a general question about what experience was most
(07:34):
useful to them in learning, They said that throughout their
fellowship experience in clinical practice was the most important, and
I'm sure this is not surprising to any listener to
this podcast when looking at the qualitative analysis of the
responses from the fellows. The author's comment on the concept
of practice variation and how differences in this were really
viewed as an important aspect of learning from this and
(07:57):
they particularly commented on how one center was more interesting
did in catheter based interventions over surgical and interestingly that
center was the Dublin program compared with the Texas program.
They also commented on a discussion comparing RV outflow stanting
with ductal stenting and BTT shunts as a particularly interesting
one in the setting of tetrology for the fellows. The
(08:19):
learners repeatedly mentioned the notion of cognitive overload and having
too much to learn in too little time and having
time management issues, which I'm sure rings true from many
who are either fellows listening to this podcast or those
who teach fellows. Finally, the authors mentioned the notion that
there is an important skill in managing uncertainty and that
(08:39):
it is a key to success for pediatric cardiologists, and
they felt that these sessions adequately demonstrated this in their discussion.
The author's state and I quote to our knowledge, this
is the first description of a sustained educational twinning partnership
between international pediatric cardiology training programs described in the literature.
Beyond the core competencies of tee, there is progressive interest
(09:02):
in developing self regulated, adaptive learners who can think critically
and managed clinically uncertain situations. One of the central premises
of the program is the tacit acknowledgement that pediatric cardiology
is a burgeoning medical specialty in which randomized controlled trial
data are limited and clinical uncertainty is common. Exposure to
(09:23):
another program in a different country, with different resources and
ways of tackling problems may expand trainee horizons on how
to care for patients and their family. Feedback on the
utility of the sessions from learners was overwhelmingly positive. Fellows
valued the case based format with ample time for discussion
both with their peers and with facilitators. The authors review
(09:45):
how exposing the fellows to uncertainty in this conference and
in general is important and encourages critical thinking. They re
emphasize the fellow's comments regarding cognitive overload and the difficulties
of balancing so much data to learn with time management
of training, and the many responsibilities that go with that.
They explained in the discussion that one of the aims
(10:05):
of the program was to encourage and enhance connections between
programs and maybe even foster collaborative research, and they point
again to the fact that twenty nine percent of the
trainees did report that the program resulted in a research
question for them. And the authors bemoaned the difficulty of
performing large, multi institutional studies, but reference the SVR trial
(10:25):
is just one demonstrating the true benefit of collaborative work
between centers. In regards to limitations, the authors point to
the small sample size of respondents, with only fifty six
percent of those asked actually responding. They also point to
the fact that only two countries are represented in this work,
meaning that it may not reflect other parts of the world,
and they also point to the difficulty in interpreting questionnaires
(10:47):
compared with actual one on one interviews. And so they
conclude this two center international Twinning partnership demonstrates an effective
online educational collaboration between two pediatric cardiology centers in the
USA and Europe. The potential for deep learning was highlighted
through the use of educational sessions that centered around case
(11:08):
based presentations, followed by discussion of practice variation and agreement
between the institutions, which were chaired by experienced pediatric cardiologists
from both centers. Trainees overwhelmingly found the sessions to be
of educational utility, particularly as they provided time for discussion
and highlighted areas of clinical uncertainty. Areas for future development
(11:29):
include embracing technology, enhanced learning, encouraging collaborative research, and international expansion. Well,
I think this study is quite interesting and demonstrating how
valuable it can be to work or at least see
how other people or groups tackle similar problems in different ways.
As someone who trained in one place and then has
worked now in three different locations each for nearly ten years,
(11:53):
I have seen firsthand how working in different environments, even
in the same city, broadens one's ideas regards management. For example,
when I was a cardiology fellow, I recall a senior
surgeon strongly bashing the ROSS operation, and the enthusiasm for
this approach was tempered also at my next two jobs. However,
now I work at Mount Sinai, which is a center
(12:15):
of excellent for the ROSS, and it would be rare
in my present center to not offer that as the
top recommendation for many forms of a yortic foul disease.
I've also seen how being able to contrast center approaches
can be a fertile lend of research questions, and my
very first paper was on bubboventricular fraiment resection, which was
something I was told was absolutely contraindicated when I was
(12:37):
a fellow in Boston, but then came to New York City,
where I learned that this was in fact the preferred
approach by doctor Jan Quagibor when obstruction at that level
would have human dynamic implications. Certainly, learning about how there
are more ways than one to manage things would seem
of great value, and this seems to me to be
one of the many benefits fellows have received from participation
(12:58):
in this wonderful collaboration that we've reviewed this week. In
the interest of time, I think we should move forward
with our conversation with the works first author doctor McMahon.
Colin McMahon is a graduate of University College in Dublin
for medical school, and interestingly he has an MBA from
the same institution as well as the Master's of Science
from the University of Maastriacht. He is Professor of Pediatric
(13:18):
Cardiology and a consultant pediatric cardiologist at University College in
Dublin and is well published in many different areas of
pediatric cardiology and particularly in this week's topic of fellow education.
It is a delight to welcome doctor McMahon all the
way from Dublin. Welcome Professor McMahon to p D Heart.
Speaker 2 (13:36):
I'm here now with doctor Colin McMahon all the way
from Dublin. Doctor McMahon, thank you very much for spending
some time right in the middle of your work day
with us on PDHART this week.
Speaker 3 (13:45):
Great Robert, thank you very much for inviting me onto
your podcast and I'm really honored to be here's my
first ever podcast. I know of your reputation and the
great work you too, so delighted to be invited and
hopefully we can have an interesting conversation.
Speaker 2 (14:00):
Thank you, Thank you very much. You know, as I
was reading this, doctor McMahon, the first thing that came
to my mind was, how did this idea even start.
Was it initially your thought that this would be a
monthly activity or did it develop into this after a
few sessions that proved successful, and what were your initial
versus shall we say, present day goals of it.
Speaker 4 (14:20):
That's a really great question to start with. So I guess,
just to give a little bit of background for.
Speaker 3 (14:26):
Your audience, I'm sort of an unusual entity in that
I spent a lot of my time training in different
centers but also different countries. So I spent a lot
of my early training in Dublin and Ireland, but then
was lucky to work in London in Great Ormond Street,
and then after being there for a few years, moved
to Texas Children's where I did fellowship. I was very
(14:46):
lucky to work under Tim Bricker and Jeff Tobin and
a wonderful group of people there, and then I also
was lucky enough to work with.
Speaker 4 (14:54):
Doctor Gava and doctor Powell in Boston when Jim Locke
was chief there.
Speaker 3 (15:00):
So it was a wonderful opportunity to train in multiple
different centers. And one of the things that was really interesting,
Robert was that people did things differently in every center.
Speaker 4 (15:09):
You worked in.
Speaker 3 (15:11):
It was a little bit different how you manage single
ventricles in Ireland compared to how you manage them in
the UK compared to maybe Boston and Texas children.
Speaker 4 (15:20):
And one of the sort.
Speaker 3 (15:22):
Of ideas that sort of arrived out of this experience
of seeing different ways of managing problems was when I
had the opportunity to speak to Dan Penny and Hugh Allen,
and I want to commend them because this would never
have happened.
Speaker 4 (15:35):
Without their input.
Speaker 3 (15:36):
And we were really looking for a way of making
education more interesting and engaging learners. And you know, I
think one of the most important things with our fellows
training them, how do we engage them to be self
regulated learners who want to go and learn themselves developed that,
you know, ability to ask interesting questions and try and
(15:58):
answer those questions. So really sort of spun out of
a conversation between Dan and myself and.
Speaker 4 (16:04):
Hugh, and we didn't know how to do it or
what to do. Is sort of developed organically interesting.
Speaker 2 (16:11):
You know, I thought that one of the more important
teaching points or accomplishments of the work you've done with
this program seems to be an effort to improve the
fellows understanding of how to manage uncertainty and decision making,
which is such a critical part of everything that we
do as pediatric cardiologists. I'm wondering how you think this
program practically has achieved that goal or has worked towards that.
Speaker 4 (16:34):
That's you're hitting. All the highlights of the article are
of Robert, So.
Speaker 3 (16:39):
You know, being aware of uncertainty I think is actually
critically important because I think having a mindset that's not
afraid to ask questions why are we doing it this way?
And you know, we've done some work on decision making,
even of simple congenital cardioglesions, and what becomes really clear
is that they're often not by binary black and white answers,
(17:02):
but actually that how we make decisions and what we
base decisions on it's often quite gray, and if you
try and force a decision into being either black or white,
you'll often lose a lot of the nuances around how
we make these decisions. The other aspect of this that
was really interesting is we're challenged in pediatric cardiology by
(17:26):
having often very complex cardiac lesions in children who are
very vulnerable, but we don't have large data sets or
randomized control trials to make definitive evidence based medical decisions,
So how do we manage those cases?
Speaker 4 (17:41):
You know?
Speaker 3 (17:42):
So I think that's why we were really open to
this concept of uncertainty and recognizing it, admitting its existence.
Speaker 4 (17:52):
How we discuss.
Speaker 3 (17:53):
Around the MDTI er the JCC conference, how to actually
make decisions for specific lesions of something interested in and
you know the concept of talking out, you know, the
process of thinking. The idea of maybe having artificial intelligence
is maybe you know, an assistant and decision making.
Speaker 4 (18:12):
All of these concepts were sort of areas.
Speaker 3 (18:14):
That are now becoming more prevalent in how we actually
make decisions. So the uncertainty aspects we're very interested in managing.
Speaker 4 (18:23):
How you actually fix the uncertainties difficult.
Speaker 3 (18:26):
We don't always have definitive answers, but I think embracing it,
talking around different potential solutions, and then also the idea
of incorporating this more into the curriculum is something we
are very keen to.
Speaker 2 (18:38):
Discuss, I have to say. And doctor McMahon, I think
at your point earlier about having the experience of different
centers and managing something is really important because I've also
worked in a number of centers. You don't have the
opportunity to hear what I said before this interview because
I recorded in advance. But one of the things that
I think is very critical is just seeing that there's
(19:00):
more than one way to do something, and a lot
of that is dependent on what the resources are of
a center, and somehow, in the end the result tends
to be pretty good through multiple ways. And it is
funny how different centers have real dogma about certain approaches
that other centers completely throw in the garbage. And so
(19:21):
I think it does highlight the uncertainty of what we
know about how to manage things. And I myself, for example,
take care of one or two Irish patients who had
all of their stage surgeries in Ireland and are doing wonderfully,
but we would not probably have managed it the same
way here, and yet the children are completely fine. So
it's just a little example that there's certainly more than
(19:43):
one way to manage things properly. You know. Another of
the important goals that you set out to achieve, according
to the paper, was to teach fellows how to better communicate.
And I think communication is just so critical and virtually
every aspect of life. How did you set out to
achieve that, and do you think you were successful in
(20:04):
improving that for the fellows?
Speaker 3 (20:06):
So you're hitting all the highlights here, Robert, you're asking
the questions I hoped you'd ask. So, I personally think
the biggest challenge is in being an effective communicator.
Speaker 4 (20:16):
And if we.
Speaker 3 (20:17):
Can't explain to families patients where they're old enough caregivers,
what's going on with their child, what the potential treatments are,
and why we think one treatment over another is a
better treatment, but also to involve them in the decision making,
then we're not really much use as doctors.
Speaker 4 (20:34):
And I think you.
Speaker 3 (20:35):
Can have a thousand papers and all sorts of eye
impact journals, but if you can't talk and deal with
people and take care of people, then I think you.
Speaker 4 (20:43):
Have a problem.
Speaker 3 (20:45):
So you know, many of the sessions that we have
where we alternate between Texas Children's in Dublin, we may
decide to discuss the topic or an interesting lesion, but
we also discuss challenging cases that are anonymized. That's really
helpful because the fellows are driving the entire process. They
present the case, we ask them to probe the questions
(21:07):
that need to be answered and have them discussed between themselves,
so they start to deal with maybe issues that they
don't always read about in a textbook or in a journal.
How to break news to families, how to decide the
challenges in making a decision with a family.
Speaker 4 (21:23):
Maybe, how to highlight that maybe.
Speaker 3 (21:25):
It's time not to keep pursuing a strategy, that maybe
we need to be thinking about quality of life for
the child, and maybe pursuing more of a passive care approach.
So these are fundamentally important areas Robert that sometimes are
overlooked a little bit in the formal educational process. The
importance of effective communication, but also humility is a really
(21:49):
important factor that we don't always know how things will evolve,
the real importance of empathy that you actually take care
of patients and not just process them. And also the
importance of active listening to actually hear what families are
worried about and give them specific answers to the questions
that worry them, not the things that we think should
(22:11):
worry them, but what's actually worrying them. And most importantly
the child or the young adult or the teenager or
the adult and general patient listening to their worries and
their concerns and what's important to them. So by discussing
these cases, I think even to make this awareness for
fellows of what's important that patients need to hear on,
(22:33):
what payer and some patients want from the experience as
a doctor patient relationship is really important. I always talk
about there's two types of doctors. There's those, unfortunately that
process patients and don't actually sit down and listen to
what families are worried about our patients are worried about.
And then there's the you know, those older doctors we
(22:55):
worked with over the years, the Barry Keynes, the dead stuffs,
who listen to families, provided care for the patient and
the family, and I think that's what we want instill
within our fellows, carrying pathetic doctors.
Speaker 2 (23:10):
Very well said and all excellent points. Yeah, I have
to say, it is always fascinating when you listen to
families learning what it is that is really bothering them,
and it very often is not what we as the
practitioner would imagine. One of the things that I always
encounter as an electrophysiologist is that one can do the
most dangerous, difficult open heart surgery on patient and they
(23:33):
can survive it, and we can be jubilant about that fact.
But if they need a pacemaker, for some families, that
is actually worse than having to have gone through the
entire process the notion that they need a pacemaker. So
it's just a small example I think of how we
can be We can be wrong if we don't listen.
(23:54):
We may miss some important issues for families if we
don't really listen to them carefully. You know, sure didn't
that say? Well, I was wondering, you know, you sort
of lumped the Fellows all together in your analysis in
the paper, But I just wondered if it was your
impression whether this collaboration between Texas and Dublin was more
(24:15):
useful or felt to be more useful by the American
or the Irish Fellows. Did you have any sense that
one group thought it was more beneficial for them than
the other, or do you think it was relatively the
same and maybe just the benefits were different for the
two groups.
Speaker 4 (24:29):
Well, I thought that was a very sensitive question to
ask them. We're worried about answer the good.
Speaker 3 (24:35):
And maybe I was worried I might get a very
negative answer from both of them. But I think if
you read the paper, ninety three percent of them found
the sessions either helpful or really helpful.
Speaker 4 (24:46):
I think that's already positive feedback.
Speaker 3 (24:48):
And seven percent were neutral, who I think were under
a lot.
Speaker 4 (24:51):
Of time pressure.
Speaker 3 (24:53):
My perception, but Roberts, both of the group's got a
lot of benefit. I think the benefit from the Dubl
group was to realize that such an incredible center like
Dan and Hughes Center, with you know, incredible numbers of
staff and specialization and state of the art facilities, you know,
are doing things incredibly well. But also that, as you
(25:15):
mentioned earlier, the outcomes in Dublin patients were actually pretty
good too, and that even our center, with maybe not
as much resources, is actually managing very complex patients in
a very similar fashion with often equal sort of outcomes,
maybe less resources though, And I think the counter is
true as well for our US Fellows colleagues, is that
(25:38):
they see maybe a center with not as much facilities
or resources managing patients, you know, with good outcomes.
Speaker 4 (25:46):
And I think you know, there are cultural.
Speaker 3 (25:49):
Differences in how organizations run, there's cultural differences in how
patients perceive how they should be managed, and I think
some of those learnings come through from both sides.
Speaker 4 (26:00):
The other thing, I thought that was really helpful for
me because.
Speaker 3 (26:04):
I'm a big believer in lifelong learning. I'm learning more
from the fellows than they're learning from me. And you know,
Hugh and myself, who were president in most of the sessions,
our role is to facilitate discussion, it's not to run it.
And the fellows often asked really great questions and they
(26:24):
often had great insight. And I think, you know, sometimes
people are quite a little bit pessimistic about working hours
and commitment, but I was really very positively buoyed by
the quality of the fellows, their thoughtfulness, their commitment to
this process, and they're insight.
Speaker 4 (26:42):
So I think both the.
Speaker 3 (26:44):
Groups of fellows got a lot out of it. I
think some of them made friendships as well, which is good.
I know, the next sort of extension would be wonderful
to have some visit the other program and you know,
actually be there in person. And then what we would
really love to see is that this process would be
you know, replicated across different pediatric cardiology groups. You know,
(27:05):
maybe invite different groups to join as well. I think
adding in a third group might be a good thing.
Particularly maybe from an l mi C country or a
different culture like South America or Africa. I think there's
a lot of potential to continue learning. The phrase we
came up with Robert was collaborative learning, and this is
a way for us to learn.
Speaker 4 (27:27):
From each other.
Speaker 3 (27:28):
And I think programs have a lot to learn from
each other. And you know, I think I think we
should be more proactive and also innovative and inventive and
how we structure education and learning. You know, it doesn't
have to be didactic. You know, board certification pig a
major stress on fellows, but we need to make learning enjoyable,
(27:51):
you know. I guess the one final thing to say
from my standpoint is just the privilege and honor of
being able to be involved in this process. For me,
it's wonderful to have such a great relationship with you
and Dan and the TCH group, but also to see
the fellows evolve in their thinking and their ability to
(28:11):
look at the patient as a human being in a
holistic way, not just an underlying Cardioglesians really fantastic here.
Speaker 2 (28:20):
Well that sounds terrific and you may not be aware,
but it's my understanding that the Texas fellows are quite
avid listeners to this podcast, so I'm sure they're going
to all be listening to what you just had to
say about them and smiling. Well, Colin, we're getting to
the end of this conversation, and again I want to
thank you for all the time you've given to us.
(28:40):
But you know, you started this endeavor, and I'm wondering
for those who might be listening and thinking, well, this
would be something that'll be great for us to start up.
Could you give anybody some pointers on how to mimic
or clone your success with this program. Yeah.
Speaker 4 (28:56):
Again, a really good point to make, Robert.
Speaker 3 (28:58):
I think willing and institutions that want to try something different.
It's an organic process by its nature, so it has.
Speaker 4 (29:07):
To sort of find its own way.
Speaker 3 (29:10):
What makes this process successful is the excellent fellows in
Dublin and Texas Joleren's, and there are loads of amazing
fellows throughout the US, but also internationally as well, and
I think finding programs that have some relation where people
have trained there and moved back to other countries might
be a good fit. Because you know the program, and
(29:31):
you have friendships and collegiality with members in the program.
You have to give up ownership of this process to
the fellows. This is the Fellows initiative. It's not Dan's
hues or mind. It's really the Fellows that drive this
and that's why it's so successful because they do it
to a really really high standard. When they present on
(29:52):
either AI or ethical issues in congenital cardiology, they put
enormous effort and produce really fantastic discuss around these topics.
Speaker 4 (30:01):
So I think engaging the Fellows in giving them ownership.
Speaker 3 (30:05):
I think having countries with different resources is a good
thing to do.
Speaker 4 (30:09):
I want to commend KK Kumar.
Speaker 3 (30:11):
Who also has done this cross continent discussion forum where
they present interesting cases, and that's a brilliant.
Speaker 4 (30:20):
Initiative as well.
Speaker 3 (30:21):
So I think having countries from affluent, well resourced centers
and maybe LMIC countries or countries and.
Speaker 4 (30:28):
Maybe lesser resources or different resources is also another good
way of doing it.
Speaker 3 (30:32):
But I think the most important thing, Robert, just to
sort of look at the overall success is people who
are excited by education, committed to it, who want to
bring holistic education to their fellows, and.
Speaker 4 (30:47):
Then who are willing to let the fellows drive the process.
That's what I would.
Speaker 2 (30:50):
Say all wonderful points, and anybody who brings up my
dear friend KK just got extra points in my mind.
So KK and I were fellows to get there. And
for those who listen to the podcast, you know that
we've had Professor Kumar on a number of times and
hope to have him on again and always an inspiring figure,
just as you have been, doctor McMahon with this wonderful
(31:12):
work that you're doing between Texas and Dublin. Again, I
want to congratulate you and your co authors on this work.
I want to congratulate the fellows at both centers for
making this work as you describe, and most of all,
want to thank you for spending time with us this
week to discuss this very innovative educational activity.
Speaker 4 (31:31):
Robert. It was an absolute pleasure and thank you very much.
Speaker 2 (31:33):
Great pleasure.
Speaker 1 (31:34):
Well, I know that most listening to doctor McMahon will
have found many points you made to be quite important.
I thought his comments about how the joint conference has
resulted in an improvement of awareness of uncertainty and decision
making to be quite important. Making a good decision and
a time of uncertainty is a very difficult skill and
one we're all tasked with as pediatric cardiologists, and so
(31:56):
anything aimed at improving this is clearly of value. I
also felt that his comments about the importance of humility
and empathy in doctors, and his notion of thinking of
patients as people and not those who we need to
process to be wise. One would think that this is
an obvious point, but I think we all know clinicians
who might benefit from reinforcement regarding the need for empathy,
(32:18):
understanding and compassion for our patients. Finally, I thought his
comments about collaborative learning and using this conference to excite
people about learning and education to be of great interest
and importance. Once again, I'd like to thank doctor McMahon
for his wise comments in time this week. To conclude
this three hundred and thirty second episode of ped Heart
Pediatric Cardiology. Today, with doctor Colin McMahon all the way
(32:41):
from Dublin, we take a trip back in time to
the twentieth century to hear one of the great Italian
messa sopranos of all time, the spectacular Fiorenza Cossotto. Cossoto
was born in Crescentino, Italy and studied singing in Turin.
She made her debut in opera at La Scala in
nineteen fifty seven, and she went to a very long
career singing major roles in both the nineteen sixties and seventies,
(33:04):
and she sang at all of the major opera houses
throughout the world, including over one hundred and forty eight
performances of the Metropolitan Opera. Today we hear her singing
the dramatic boilos sapete from the great one act opera
of Mascagne entitled Cavalria Rusticana. Thank you for joining me
for this episode, and thanks once again to doctor McMahon.
(33:24):
I hope I'll have a good week ahead. You losing
(34:03):
this fall, m.
Speaker 2 (35:03):
Look a.
Speaker 4 (35:05):
Look at it. It's don't get it anymore.
Speaker 1 (35:11):
It's at any people follow The city is sat
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount Sinai, where I'm also the Chief of Pediatric Cardiology.
Thank you for joining me for this three hundred and
thirty second episode of Pdheart. I hope all enjoyed last
week's co branded episode with the SADS Foundation, in which
we spoke to doctor Charles Barrul about exciting new technologies
(00:39):
for pacing in children and those with congenital heart disease.
For those of you interested in electrophysiology, I'd certainly recommend
you take to listen to last week's three hundred and
thirty first episode. As I say most weeks, if you'd
like to get in touch with me, my email is
easy to remember. It's pdheart at gmail dot com. This
week we move on to the world of fellow education
(01:00):
in cardiology. The title of the work we'll be reviewing
is Twinning International Pediatric Cardiology Fellowship Programs, a transformative education
experience for trainees with potential for global adoption. The first
author of this work is Sean Kelleher and the senior author,
Colin McMahon, and the authors come to us from the
Department of Pediatric Cardiology at Children's Health Ireland at Crumlin, Dublin, Ireland,
(01:24):
the Department of Pediatric Cardiology at Texas Children's Hospital in Houston, Texas,
UCD School of Medicine in Bellfield, Dublin in Ireland, and
finally Mastrict School of Health Professions Education in Mastrik, the Netherlands.
When we're done reviewing this paper, I'm thrilled to mention
that the senior author, doctor McMahon will be speaking with
us all the way from Dublin. Therefore, let's move straight
(01:45):
on to this article and then a conversation with its
senior author. This week's work begins with a few comments
about a novel educational partnership that was created between the
Cardiology fellowship programs at Texas Children's Hospital and Children's Health
in Dublin, Ireland. The authors mention that since the COVID
nineteen pandemic, they have observed that there has been, to
use their words, an unprecedented willingness to embrace online learning formats,
(02:09):
and they suggest that webinars are one such example, and
I might add one might say that podcasts are a
similarly accepted format. The authors explain that webinars allow for
improved attendance to conferences, and they posit that they may
enhance what they refer to as deep learning. The authors
explain that the partnership between the Dublin and Houston programs
essentially was an alternate monthly conference in which there was
(02:32):
a didactic lecture or a case presentation. Both were usually
presented by a fellow at one of the two centers,
followed by a discussion that was chaired by experienced facilitators,
and eventually followed by a question and answer session. The
authors then define what they mean by the term twinning
used in the work's title, and they explain that this
is a collaborative model whereby two communities partner to share resources, knowledge,
(02:55):
and staffing to achieve a common goal, and they describe
this concept charding with the European Union, in which member
countries work together to achieve goals. They then reference prior
works showing that it was demonstrated to have benefit in
low income countries. The investigators then explained that the partnership
between Texas Childrens and the Dublin Group developed over a
four year period, and there's a table Table one on
(03:18):
page five hundred and eighty one that shows the differences
between the programs, and I'll just mention a few of
the highlights. For example, there are three surgeons in Dublin
versus eight in Houston. There's a total of fourteen pediatric
cardiologists between the member Irish programs at Crumlin and Royal
Belfast Hospital, but sixty eight at Texas Children's. Texas has
(03:39):
seven categorical fellows per year and seven subspecialty ones, and
Dublin has one to two categorical fellows with one additional pediatrician,
meaning that the Dublin program has a total of about
six fellows and Texas about twenty. The Dublin program performs
roughly four hundred and fifty surgeries annually and the Houston
program one thousand in one hundred and fifty, with six
(04:01):
hundred and fifty or so catheterizations in Dublin and fourteen
hundred and fifty in Houston. For those interested in other
differences between these programs, I would, as usual recommend it
all go to the paper and read some of the
fascinating differences, and the link to the paper will be
in the show notes. Despite these differences, the authors explained
that the two very different institutions share a number of
(04:22):
critically important goals, including providing excellent care to infants and
children with congenital heart disease and acquired heart disease, and
the development of a bridge or collaboration between two internationally
respected and known centers, which seem to have been built
in part due to a relationship between doctor McMahon in
Ireland and doctors Penny and Allen and Texas Children. And
(04:42):
for sure, I'm sure we will all want to hear
how this actually got started. The authors explain that the
desired competency of the Fellows as broad medical knowledge, technical mastery,
particularly an echo, and also increasing emphasis on excellent communication
and challenging situations. They explained that the were also trying
to encourage critical thinking in a specialty where we often
(05:03):
don't have large clinical trials upon which to base decisions,
and how to make these sorts of decisions in the
absence of this sort of hard data, while also emphasizing
how the two centers come to different decisions, sometimes about
the same case. With this as a background, the authors
explained that the goal of the study was to evaluate
the utility of the program as perceived by the trainees
(05:24):
in both centers, using both quantitative and qualitative measures, with
a secondary aim of learning more about pediatric cardiology fellows
perception of training in the field and the difficulties that
are encountered. The authors basically had the fellows answer a
questionnaire which was offered via email, and the questions asked
were both closed ended ones and open ended. The questions
(05:45):
asked are reviewed in the paper and the methodology used
by the authors is of interest and perhaps beyond the
scope of a podcast, but suffice it to say that
they used standard open and closed question techniques to assess
answers to the survey and on to the results. All
the authors explained that six of the Irish Fellows and
twenty of the Texas Children Fellows were invited to participate,
(06:06):
and in total, fourteen fellows or fifty four percent of
those who were asked to participate, actually did. Seventy one
percent of the fellows or ten were from the Texas program,
while the remaining four were from Ireland. And so perhaps
one of the most important questions, did the fellows actually
find these conferences helpful? And the answer was that ninety
three percent answered that they did, with the remaining seven
(06:29):
percent answering in neutral. The topics reviewed are listed in
the report, but the most highly ranked session was a
management case of VSDs and how management differed between the
United States and Ireland, and the second highest ranked session
was management of aortica trisia with VSD with normal biventricular dimensions.
(06:49):
The majority, or seventy one percent of the respondents felt
that the sessions highlighted areas of clinical uncertainty in practice
and spoke about how different the practices were in the
different locales in regard to difficulties or areas for improvement.
I think that most listening would not be surprised to
learn that finding time for participation and attending was a
major concern for the fellows, with fifty percent stating that
(07:11):
it was hard to find time to do this and
the reason for this in most cases was significant clinical responsibility.
About twenty nine percent or about a third, were able
to generate a research question from participation, and the majority
of the participants thought that extending this to other centers
would even improve upon the learning experience. Interestingly, when fellows
were asked a general question about what experience was most
(07:34):
useful to them in learning, They said that throughout their
fellowship experience in clinical practice was the most important, and
I'm sure this is not surprising to any listener to
this podcast when looking at the qualitative analysis of the
responses from the fellows. The author's comment on the concept
of practice variation and how differences in this were really
viewed as an important aspect of learning from this and
(07:57):
they particularly commented on how one center was more interesting
did in catheter based interventions over surgical and interestingly that
center was the Dublin program compared with the Texas program.
They also commented on a discussion comparing RV outflow stanting
with ductal stenting and BTT shunts as a particularly interesting
one in the setting of tetrology for the fellows. The
(08:19):
learners repeatedly mentioned the notion of cognitive overload and having
too much to learn in too little time and having
time management issues, which I'm sure rings true from many
who are either fellows listening to this podcast or those
who teach fellows. Finally, the authors mentioned the notion that
there is an important skill in managing uncertainty and that
(08:39):
it is a key to success for pediatric cardiologists, and
they felt that these sessions adequately demonstrated this in their discussion.
The author's state and I quote to our knowledge, this
is the first description of a sustained educational twinning partnership
between international pediatric cardiology training programs described in the literature.
Beyond the core competencies of tee, there is progressive interest
(09:02):
in developing self regulated, adaptive learners who can think critically
and managed clinically uncertain situations. One of the central premises
of the program is the tacit acknowledgement that pediatric cardiology
is a burgeoning medical specialty in which randomized controlled trial
data are limited and clinical uncertainty is common. Exposure to
(09:23):
another program in a different country, with different resources and
ways of tackling problems may expand trainee horizons on how
to care for patients and their family. Feedback on the
utility of the sessions from learners was overwhelmingly positive. Fellows
valued the case based format with ample time for discussion
both with their peers and with facilitators. The authors review
(09:45):
how exposing the fellows to uncertainty in this conference and
in general is important and encourages critical thinking. They re
emphasize the fellow's comments regarding cognitive overload and the difficulties
of balancing so much data to learn with time management
of training, and the many responsibilities that go with that.
They explained in the discussion that one of the aims
(10:05):
of the program was to encourage and enhance connections between
programs and maybe even foster collaborative research, and they point
again to the fact that twenty nine percent of the
trainees did report that the program resulted in a research
question for them. And the authors bemoaned the difficulty of
performing large, multi institutional studies, but reference the SVR trial
(10:25):
is just one demonstrating the true benefit of collaborative work
between centers. In regards to limitations, the authors point to
the small sample size of respondents, with only fifty six
percent of those asked actually responding. They also point to
the fact that only two countries are represented in this work,
meaning that it may not reflect other parts of the world,
and they also point to the difficulty in interpreting questionnaires
(10:47):
compared with actual one on one interviews. And so they
conclude this two center international Twinning partnership demonstrates an effective
online educational collaboration between two pediatric cardiology centers in the
USA and Europe. The potential for deep learning was highlighted
through the use of educational sessions that centered around case
(11:08):
based presentations, followed by discussion of practice variation and agreement
between the institutions, which were chaired by experienced pediatric cardiologists
from both centers. Trainees overwhelmingly found the sessions to be
of educational utility, particularly as they provided time for discussion
and highlighted areas of clinical uncertainty. Areas for future development
(11:29):
include embracing technology, enhanced learning, encouraging collaborative research, and international expansion. Well,
I think this study is quite interesting and demonstrating how
valuable it can be to work or at least see
how other people or groups tackle similar problems in different ways.
As someone who trained in one place and then has
worked now in three different locations each for nearly ten years,
(11:53):
I have seen firsthand how working in different environments, even
in the same city, broadens one's ideas regards management. For example,
when I was a cardiology fellow, I recall a senior
surgeon strongly bashing the ROSS operation, and the enthusiasm for
this approach was tempered also at my next two jobs. However,
now I work at Mount Sinai, which is a center
(12:15):
of excellent for the ROSS, and it would be rare
in my present center to not offer that as the
top recommendation for many forms of a yortic foul disease.
I've also seen how being able to contrast center approaches
can be a fertile lend of research questions, and my
very first paper was on bubboventricular fraiment resection, which was
something I was told was absolutely contraindicated when I was
(12:37):
a fellow in Boston, but then came to New York City,
where I learned that this was in fact the preferred
approach by doctor Jan Quagibor when obstruction at that level
would have human dynamic implications. Certainly, learning about how there
are more ways than one to manage things would seem
of great value, and this seems to me to be
one of the many benefits fellows have received from participation
(12:58):
in this wonderful collaboration that we've reviewed this week. In
the interest of time, I think we should move forward
with our conversation with the works first author doctor McMahon.
Colin McMahon is a graduate of University College in Dublin
for medical school, and interestingly he has an MBA from
the same institution as well as the Master's of Science
from the University of Maastriacht. He is Professor of Pediatric
(13:18):
Cardiology and a consultant pediatric cardiologist at University College in
Dublin and is well published in many different areas of
pediatric cardiology and particularly in this week's topic of fellow education.
It is a delight to welcome doctor McMahon all the
way from Dublin. Welcome Professor McMahon to p D Heart.
Speaker 2 (13:36):
I'm here now with doctor Colin McMahon all the way
from Dublin. Doctor McMahon, thank you very much for spending
some time right in the middle of your work day
with us on PDHART this week.
Speaker 3 (13:45):
Great Robert, thank you very much for inviting me onto
your podcast and I'm really honored to be here's my
first ever podcast. I know of your reputation and the
great work you too, so delighted to be invited and
hopefully we can have an interesting conversation.
Speaker 2 (14:00):
Thank you, Thank you very much. You know, as I
was reading this, doctor McMahon, the first thing that came
to my mind was, how did this idea even start.
Was it initially your thought that this would be a
monthly activity or did it develop into this after a
few sessions that proved successful, and what were your initial
versus shall we say, present day goals of it.
Speaker 4 (14:20):
That's a really great question to start with. So I guess,
just to give a little bit of background for.
Speaker 3 (14:26):
Your audience, I'm sort of an unusual entity in that
I spent a lot of my time training in different
centers but also different countries. So I spent a lot
of my early training in Dublin and Ireland, but then
was lucky to work in London in Great Ormond Street,
and then after being there for a few years, moved
to Texas Children's where I did fellowship. I was very
(14:46):
lucky to work under Tim Bricker and Jeff Tobin and
a wonderful group of people there, and then I also
was lucky enough to work with.
Speaker 4 (14:54):
Doctor Gava and doctor Powell in Boston when Jim Locke
was chief there.
Speaker 3 (15:00):
So it was a wonderful opportunity to train in multiple
different centers. And one of the things that was really interesting,
Robert was that people did things differently in every center.
Speaker 4 (15:09):
You worked in.
Speaker 3 (15:11):
It was a little bit different how you manage single
ventricles in Ireland compared to how you manage them in
the UK compared to maybe Boston and Texas children.
Speaker 4 (15:20):
And one of the sort.
Speaker 3 (15:22):
Of ideas that sort of arrived out of this experience
of seeing different ways of managing problems was when I
had the opportunity to speak to Dan Penny and Hugh Allen,
and I want to commend them because this would never
have happened.
Speaker 4 (15:35):
Without their input.
Speaker 3 (15:36):
And we were really looking for a way of making
education more interesting and engaging learners. And you know, I
think one of the most important things with our fellows
training them, how do we engage them to be self
regulated learners who want to go and learn themselves developed that,
you know, ability to ask interesting questions and try and
(15:58):
answer those questions. So really sort of spun out of
a conversation between Dan and myself and.
Speaker 4 (16:04):
Hugh, and we didn't know how to do it or
what to do. Is sort of developed organically interesting.
Speaker 2 (16:11):
You know, I thought that one of the more important
teaching points or accomplishments of the work you've done with
this program seems to be an effort to improve the
fellows understanding of how to manage uncertainty and decision making,
which is such a critical part of everything that we
do as pediatric cardiologists. I'm wondering how you think this
program practically has achieved that goal or has worked towards that.
Speaker 4 (16:34):
That's you're hitting. All the highlights of the article are
of Robert, So.
Speaker 3 (16:39):
You know, being aware of uncertainty I think is actually
critically important because I think having a mindset that's not
afraid to ask questions why are we doing it this way?
And you know, we've done some work on decision making,
even of simple congenital cardioglesions, and what becomes really clear
is that they're often not by binary black and white answers,
(17:02):
but actually that how we make decisions and what we
base decisions on it's often quite gray, and if you
try and force a decision into being either black or white,
you'll often lose a lot of the nuances around how
we make these decisions. The other aspect of this that
was really interesting is we're challenged in pediatric cardiology by
(17:26):
having often very complex cardiac lesions in children who are
very vulnerable, but we don't have large data sets or
randomized control trials to make definitive evidence based medical decisions,
So how do we manage those cases?
Speaker 4 (17:41):
You know?
Speaker 3 (17:42):
So I think that's why we were really open to
this concept of uncertainty and recognizing it, admitting its existence.
Speaker 4 (17:52):
How we discuss.
Speaker 3 (17:53):
Around the MDTI er the JCC conference, how to actually
make decisions for specific lesions of something interested in and
you know the concept of talking out, you know, the
process of thinking. The idea of maybe having artificial intelligence
is maybe you know, an assistant and decision making.
Speaker 4 (18:12):
All of these concepts were sort of areas.
Speaker 3 (18:14):
That are now becoming more prevalent in how we actually
make decisions. So the uncertainty aspects we're very interested in managing.
Speaker 4 (18:23):
How you actually fix the uncertainties difficult.
Speaker 3 (18:26):
We don't always have definitive answers, but I think embracing it,
talking around different potential solutions, and then also the idea
of incorporating this more into the curriculum is something we
are very keen to.
Speaker 2 (18:38):
Discuss, I have to say. And doctor McMahon, I think
at your point earlier about having the experience of different
centers and managing something is really important because I've also
worked in a number of centers. You don't have the
opportunity to hear what I said before this interview because
I recorded in advance. But one of the things that
I think is very critical is just seeing that there's
(19:00):
more than one way to do something, and a lot
of that is dependent on what the resources are of
a center, and somehow, in the end the result tends
to be pretty good through multiple ways. And it is
funny how different centers have real dogma about certain approaches
that other centers completely throw in the garbage. And so
(19:21):
I think it does highlight the uncertainty of what we
know about how to manage things. And I myself, for example,
take care of one or two Irish patients who had
all of their stage surgeries in Ireland and are doing wonderfully,
but we would not probably have managed it the same
way here, and yet the children are completely fine. So
it's just a little example that there's certainly more than
(19:43):
one way to manage things properly. You know. Another of
the important goals that you set out to achieve, according
to the paper, was to teach fellows how to better communicate.
And I think communication is just so critical and virtually
every aspect of life. How did you set out to
achieve that, and do you think you were successful in
(20:04):
improving that for the fellows?
Speaker 3 (20:06):
So you're hitting all the highlights here, Robert, you're asking
the questions I hoped you'd ask. So, I personally think
the biggest challenge is in being an effective communicator.
Speaker 4 (20:16):
And if we.
Speaker 3 (20:17):
Can't explain to families patients where they're old enough caregivers,
what's going on with their child, what the potential treatments are,
and why we think one treatment over another is a
better treatment, but also to involve them in the decision making,
then we're not really much use as doctors.
Speaker 4 (20:34):
And I think you.
Speaker 3 (20:35):
Can have a thousand papers and all sorts of eye
impact journals, but if you can't talk and deal with
people and take care of people, then I think you.
Speaker 4 (20:43):
Have a problem.
Speaker 3 (20:45):
So you know, many of the sessions that we have
where we alternate between Texas Children's in Dublin, we may
decide to discuss the topic or an interesting lesion, but
we also discuss challenging cases that are anonymized. That's really
helpful because the fellows are driving the entire process. They
present the case, we ask them to probe the questions
(21:07):
that need to be answered and have them discussed between themselves,
so they start to deal with maybe issues that they
don't always read about in a textbook or in a journal.
How to break news to families, how to decide the
challenges in making a decision with a family.
Speaker 4 (21:23):
Maybe, how to highlight that maybe.
Speaker 3 (21:25):
It's time not to keep pursuing a strategy, that maybe
we need to be thinking about quality of life for
the child, and maybe pursuing more of a passive care approach.
So these are fundamentally important areas Robert that sometimes are
overlooked a little bit in the formal educational process. The
importance of effective communication, but also humility is a really
(21:49):
important factor that we don't always know how things will evolve,
the real importance of empathy that you actually take care
of patients and not just process them. And also the
importance of active listening to actually hear what families are
worried about and give them specific answers to the questions
that worry them, not the things that we think should
(22:11):
worry them, but what's actually worrying them. And most importantly
the child or the young adult or the teenager or
the adult and general patient listening to their worries and
their concerns and what's important to them. So by discussing
these cases, I think even to make this awareness for
fellows of what's important that patients need to hear on,
(22:33):
what payer and some patients want from the experience as
a doctor patient relationship is really important. I always talk
about there's two types of doctors. There's those, unfortunately that
process patients and don't actually sit down and listen to
what families are worried about our patients are worried about.
And then there's the you know, those older doctors we
(22:55):
worked with over the years, the Barry Keynes, the dead stuffs,
who listen to families, provided care for the patient and
the family, and I think that's what we want instill
within our fellows, carrying pathetic doctors.
Speaker 2 (23:10):
Very well said and all excellent points. Yeah, I have
to say, it is always fascinating when you listen to
families learning what it is that is really bothering them,
and it very often is not what we as the
practitioner would imagine. One of the things that I always
encounter as an electrophysiologist is that one can do the
most dangerous, difficult open heart surgery on patient and they
(23:33):
can survive it, and we can be jubilant about that fact.
But if they need a pacemaker, for some families, that
is actually worse than having to have gone through the
entire process the notion that they need a pacemaker. So
it's just a small example I think of how we
can be We can be wrong if we don't listen.
(23:54):
We may miss some important issues for families if we
don't really listen to them carefully. You know, sure didn't
that say? Well, I was wondering, you know, you sort
of lumped the Fellows all together in your analysis in
the paper, But I just wondered if it was your
impression whether this collaboration between Texas and Dublin was more
(24:15):
useful or felt to be more useful by the American
or the Irish Fellows. Did you have any sense that
one group thought it was more beneficial for them than
the other, or do you think it was relatively the
same and maybe just the benefits were different for the
two groups.
Speaker 4 (24:29):
Well, I thought that was a very sensitive question to
ask them. We're worried about answer the good.
Speaker 3 (24:35):
And maybe I was worried I might get a very
negative answer from both of them. But I think if
you read the paper, ninety three percent of them found
the sessions either helpful or really helpful.
Speaker 4 (24:46):
I think that's already positive feedback.
Speaker 3 (24:48):
And seven percent were neutral, who I think were under
a lot.
Speaker 4 (24:51):
Of time pressure.
Speaker 3 (24:53):
My perception, but Roberts, both of the group's got a
lot of benefit. I think the benefit from the Dubl
group was to realize that such an incredible center like
Dan and Hughes Center, with you know, incredible numbers of
staff and specialization and state of the art facilities, you know,
are doing things incredibly well. But also that, as you
(25:15):
mentioned earlier, the outcomes in Dublin patients were actually pretty
good too, and that even our center, with maybe not
as much resources, is actually managing very complex patients in
a very similar fashion with often equal sort of outcomes,
maybe less resources though, And I think the counter is
true as well for our US Fellows colleagues, is that
(25:38):
they see maybe a center with not as much facilities
or resources managing patients, you know, with good outcomes.
Speaker 4 (25:46):
And I think you know, there are cultural.
Speaker 3 (25:49):
Differences in how organizations run, there's cultural differences in how
patients perceive how they should be managed, and I think
some of those learnings come through from both sides.
Speaker 4 (26:00):
The other thing, I thought that was really helpful for
me because.
Speaker 3 (26:04):
I'm a big believer in lifelong learning. I'm learning more
from the fellows than they're learning from me. And you know,
Hugh and myself, who were president in most of the sessions,
our role is to facilitate discussion, it's not to run it.
And the fellows often asked really great questions and they
(26:24):
often had great insight. And I think, you know, sometimes
people are quite a little bit pessimistic about working hours
and commitment, but I was really very positively buoyed by
the quality of the fellows, their thoughtfulness, their commitment to
this process, and they're insight.
Speaker 4 (26:42):
So I think both the.
Speaker 3 (26:44):
Groups of fellows got a lot out of it. I
think some of them made friendships as well, which is good.
I know, the next sort of extension would be wonderful
to have some visit the other program and you know,
actually be there in person. And then what we would
really love to see is that this process would be
you know, replicated across different pediatric cardiology groups. You know,
(27:05):
maybe invite different groups to join as well. I think
adding in a third group might be a good thing.
Particularly maybe from an l mi C country or a
different culture like South America or Africa. I think there's
a lot of potential to continue learning. The phrase we
came up with Robert was collaborative learning, and this is
a way for us to learn.
Speaker 4 (27:27):
From each other.
Speaker 3 (27:28):
And I think programs have a lot to learn from
each other. And you know, I think I think we
should be more proactive and also innovative and inventive and
how we structure education and learning. You know, it doesn't
have to be didactic. You know, board certification pig a
major stress on fellows, but we need to make learning enjoyable,
(27:51):
you know. I guess the one final thing to say
from my standpoint is just the privilege and honor of
being able to be involved in this process. For me,
it's wonderful to have such a great relationship with you
and Dan and the TCH group, but also to see
the fellows evolve in their thinking and their ability to
(28:11):
look at the patient as a human being in a
holistic way, not just an underlying Cardioglesians really fantastic here.
Speaker 2 (28:20):
Well that sounds terrific and you may not be aware,
but it's my understanding that the Texas fellows are quite
avid listeners to this podcast, so I'm sure they're going
to all be listening to what you just had to
say about them and smiling. Well, Colin, we're getting to
the end of this conversation, and again I want to
thank you for all the time you've given to us.
(28:40):
But you know, you started this endeavor, and I'm wondering
for those who might be listening and thinking, well, this
would be something that'll be great for us to start up.
Could you give anybody some pointers on how to mimic
or clone your success with this program. Yeah.
Speaker 4 (28:56):
Again, a really good point to make, Robert.
Speaker 3 (28:58):
I think willing and institutions that want to try something different.
It's an organic process by its nature, so it has.
Speaker 4 (29:07):
To sort of find its own way.
Speaker 3 (29:10):
What makes this process successful is the excellent fellows in
Dublin and Texas Joleren's, and there are loads of amazing
fellows throughout the US, but also internationally as well, and
I think finding programs that have some relation where people
have trained there and moved back to other countries might
be a good fit. Because you know the program, and
(29:31):
you have friendships and collegiality with members in the program.
You have to give up ownership of this process to
the fellows. This is the Fellows initiative. It's not Dan's
hues or mind. It's really the Fellows that drive this
and that's why it's so successful because they do it
to a really really high standard. When they present on
(29:52):
either AI or ethical issues in congenital cardiology, they put
enormous effort and produce really fantastic discuss around these topics.
Speaker 4 (30:01):
So I think engaging the Fellows in giving them ownership.
Speaker 3 (30:05):
I think having countries with different resources is a good
thing to do.
Speaker 4 (30:09):
I want to commend KK Kumar.
Speaker 3 (30:11):
Who also has done this cross continent discussion forum where
they present interesting cases, and that's a brilliant.
Speaker 4 (30:20):
Initiative as well.
Speaker 3 (30:21):
So I think having countries from affluent, well resourced centers
and maybe LMIC countries or countries and.
Speaker 4 (30:28):
Maybe lesser resources or different resources is also another good
way of doing it.
Speaker 3 (30:32):
But I think the most important thing, Robert, just to
sort of look at the overall success is people who
are excited by education, committed to it, who want to
bring holistic education to their fellows, and.
Speaker 4 (30:47):
Then who are willing to let the fellows drive the process.
That's what I would.
Speaker 2 (30:50):
Say all wonderful points, and anybody who brings up my
dear friend KK just got extra points in my mind.
So KK and I were fellows to get there. And
for those who listen to the podcast, you know that
we've had Professor Kumar on a number of times and
hope to have him on again and always an inspiring figure,
just as you have been, doctor McMahon with this wonderful
(31:12):
work that you're doing between Texas and Dublin. Again, I
want to congratulate you and your co authors on this work.
I want to congratulate the fellows at both centers for
making this work as you describe, and most of all,
want to thank you for spending time with us this
week to discuss this very innovative educational activity.
Speaker 4 (31:31):
Robert. It was an absolute pleasure and thank you very much.
Speaker 2 (31:33):
Great pleasure.
Speaker 1 (31:34):
Well, I know that most listening to doctor McMahon will
have found many points you made to be quite important.
I thought his comments about how the joint conference has
resulted in an improvement of awareness of uncertainty and decision
making to be quite important. Making a good decision and
a time of uncertainty is a very difficult skill and
one we're all tasked with as pediatric cardiologists, and so
(31:56):
anything aimed at improving this is clearly of value. I
also felt that his comments about the importance of humility
and empathy in doctors, and his notion of thinking of
patients as people and not those who we need to
process to be wise. One would think that this is
an obvious point, but I think we all know clinicians
who might benefit from reinforcement regarding the need for empathy,
(32:18):
understanding and compassion for our patients. Finally, I thought his
comments about collaborative learning and using this conference to excite
people about learning and education to be of great interest
and importance. Once again, I'd like to thank doctor McMahon
for his wise comments in time this week. To conclude
this three hundred and thirty second episode of ped Heart
Pediatric Cardiology. Today, with doctor Colin McMahon all the way
(32:41):
from Dublin, we take a trip back in time to
the twentieth century to hear one of the great Italian
messa sopranos of all time, the spectacular Fiorenza Cossotto. Cossoto
was born in Crescentino, Italy and studied singing in Turin.
She made her debut in opera at La Scala in
nineteen fifty seven, and she went to a very long
career singing major roles in both the nineteen sixties and seventies,
(33:04):
and she sang at all of the major opera houses
throughout the world, including over one hundred and forty eight
performances of the Metropolitan Opera. Today we hear her singing
the dramatic boilos sapete from the great one act opera
of Mascagne entitled Cavalria Rusticana. Thank you for joining me
for this episode, and thanks once again to doctor McMahon.
(33:24):
I hope I'll have a good week ahead. You losing
(34:03):
this fall, m.
Speaker 2 (35:03):
Look a.
Speaker 4 (35:05):
Look at it. It's don't get it anymore.
Speaker 1 (35:11):
It's at any people follow The city is sat
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