Indian J Thorac Cardiovasc Surg (2016) 32:165–173 DOI 10.1007/s12055-016-0445-2

PRESIDENTIAL ADDRESS

The Trainer, the Trainee, and the Trained On mentorship for the future of our specialty Suresh Gururaja Rao 1

Published online: 12 August 2016 # Indian Association of Cardiovascular-Thoracic Surgeons 2016

Good Afternoon ladies and gentlemen. It is my privilege and honor to deliver the Presidential Oration of the 62nd Annual Conference of the Indian Association of Cardiovascular and Thoracic Surgeons of India. I sincerely thank you for this honor and for letting me occupy this prestigious position. I consider this as the pinnacle of my professional career, thanks to your recognition, and I shall value and cherish it for the rest of my life. To reach this coveted position, I have had good wishes and blessings showered on me, along with help and influences from many people. All these have helped shape my career. It would be most ungrateful on my part if I do not recognize and thank these important gems in my life. I would like to first thank my parents without whom I would not be here addressing you! They gave me a stable and fabled childhood, a loving and emotionally secure home to develop myself, and were the best role models a child could aspire for!

This paper was presented at the 62nd Annual Conference of Indian Association of Cardiovascular-Thoracic Surgeons, Lucknow, February, 2016 * Suresh Gururaja Rao [email protected]; [email protected] 1

Childrens Heart Centre, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra 400053, India

Given the rigors of the specialty of cardiovascular surgery, spouses of cardiac surgeons are called upon to sacrifice a lot to hold the “nest”! I wish to thank my wife Anuradha, for having stood by me in trying times so common in the development of a cardiac surgeon. By her cheerful demeanor and ability to multitask in managing the nest, I could pursue my subspecialty wholeheartedly. My two children grew up “quickly” as it appears. It is always a matter of pride to see the kids grow up, but it is also tinged with some regrets that we could not spend enough time with them in the process, due to the demands of the specialty! My initiation into cardiovascular and thoracic surgery was done by the late Dr. B.L. Gupta. An astute thoracic surgeon and a giant of his times in this field, he was instrumental in kindling my interest to take up CVTS as a specialty. Working with Dr. Dev Saksena crystallized my desire to pursue CVTS, and in him, I saw a role model of a well trained and confidant cardiovascular surgeon worthy of emulation by a young impressionable surgeon. Our past president, the late Dr. Ashok Hishikar, who was my confidante in Nanavati Hospital when I used to accompany Dr. Gupta there, made me see the importance of sound, early, and structured training that is necessary in cardiovascular and thoracic surgery, and counseled me to go South for better training. It was fortuitous that a fortnight later, the MCh (CVTS) admission advertisement of Sree Chitra Institute (SCTIMST) appeared and I could successfully make it there to join their residency program.

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Dr. Suresh G Rao

At SCTIMST, I could experience what a structured training program could offer in the development of a CVT Surgeon. The institute exposed me to all aspects of CV laboratory research (as the Chitra Valve was being developed in my tenure there) and gave me a sound foundation in CVT surgery in an academic environment which in hindsight, I believe, is so very essential in the making of a CVT Surgeon. I am most thankful for this to Prof. M.S. Valiathan, Prof. Mohansingh, Prof, Neelakandhan, Prof. Sankar Kumar, and Prof. Shyamkrishnan.

Dr. BL Gupta, Dr. DS Saksena, and Dr. Ashok Hishikar

Dr. MS Valiathan, Dr. Mohan Singh, Dr. KS Neelakandhan, Dr. Sankar Kumar, and Dr. K.G. Shyamkrishnan

Once my formal training was completed, the next move was to find a mentor! I was most fortunate that at the time I was looking around, Dr. K.M. Cherian moved out of Railway Hospital to start the Madras Medical Mission. The period that I spent at MMM working with Dr. Cherian has had the greatest influence on my development as a congenital heart surgeon. At his behest, I could spend time with Dr. Alan Kerr in Auckland, Prof. Tim Cartmill and Dr. Graham Nunn in Sydney, and Dr. Albert Pacifico in University of Alabama at Birmingham. Each of these individuals were giants in their own way and working with them was like attending a “finishing school” to complete my formal training in congenital heart surgery.

Dr. Tim Cartmill, Dr. AD Pacifico, Dr. Graham Nunn, Mr. Alan Kerr, and Dr. K.M. Cherian

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Dr. K.M. Cherian and MMM provided a great platform for young surgeons to grow and develop themselves. A visionary that he was,… coupled with his passion to develop a congenital heart program of excellence in India, Dr. Cherian and all of us at MMM commissioned the first exclusive Pediatric Cardiac Surgical ICU, which was inaugurated by Dr. Donald Ross in 1989. The surgeons involved in congenital heart surgery at that time were, Dr. K.R Balakrishnan, Dr. S. Rajan, Dr. L. Mohanakrishnan, Dr. Richard Saldhana, Dr. Cherian, and myself. It was in 1994 soon after my return to India that we introduced MUF in congenital heart surgery for the first time in our country. The freedom and impetus given by Dr. Cherian for introduction of newer techniques, and practices brought in by his younger colleagues, further contributed to the growth of the program and the institution. It is always the dream of any surgeon to progress to head a unit and direct a program one day. Against the background of the years spent and the confidence gained at MMM, I accepted the offer from Mata Amritananda Mayi’s (AMMA’s) Institution to move to Kochi to start the Congenital Heart Program at the Amrita Institute of Medical Sciences. I considered it a blessing, an honor, and a very rare privilege to be given this challenging opportunity by AMMA.

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The unstinted commitment of the AIMS management towards excellence, the camaraderie prevalent among the consultant and other staff and the goodwill of the whole organization served as a catalyst and enabled us to take the cardiac program at AIMS and the Congenital Heart Program in particular to one of the largest programs in India with outstanding outcomes. I would be failing in my duty if do not recognize the contributions of my colleague pediatric cardiologist of national repute at AIMS, Dr. R. Krishnakumar. More than a traditional pediatric cardiologist, he was a live wire and a “Surgeon’s” cardiologist. He took active part in the development of the team, practices and training, and ICU which greatly contributed to the excellence in outcomes. In Dr. Shivaprakasha, I had a surgical colleague par excellence and a confidante. Our professional interactions, problem solving, and discussions always served as an educational and enlightening experience to me.

With Dr. R. Krishna Kumar and the dynamic Pediatric Cardiac team at AIMS, 2000

With AMMA (Mata Amritananda Mayi)

The period at Amrita from 1998 to 2009 was one of professional consolidation and growth. I was blessed to have very supportive and wonderful colleagues in Prof. Neelakandhan in the early years, Dr. V. Satya Prasad (who moved with me from MMM to start the Adult Cardiac Surgery Program at Amrita), Dr. Shiv K. Nair, and Dr. K. Shivaprakasha. We were ably supported by our cardiology colleagues particularly the late Dr. K.K. Haridas and Dr. R. Krishna Kumar. I also had the opportunity to work with a host of younger surgeons at AIMS all of whom I am proud to say today, are heading various CVTS units across the state of Kerala and also across the country.

With Dr. KM Cherian and his proteges

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With Mrs. Tina Ambani and Mr. Jamir, Governor of Maharashtra at the inauguration of the Children’s Heart Centre at KDA Hospital 2009

With my team at Children’s Heart Centre, KDAH

It was in 2009… after exactly 25 years that I left Mumbai to train in SCTIMST, that I returned to set up the Children’s Heart Centre at the newly commissioned Kokilaben Dhirubhai Ambani Hospital where I am working currently. A full time practice system, a group of extremely committed individuals keen to build a center of excellence, a world class infrastructure, and a very keen management to promote congenital heart surgery, compelled me to move to this busy metropolis and endeavor to contribute to the practice of congenital heart surgery in Western India. Over the last 7 years, I am immensely proud of the contributions made by our team at Kokilaben Hospital towards promoting excellence in congenital heart surgery in this part of the country. Ladies and Gentlemen,… after my acknowledgements to all the people in my life who made me what I am today, I would now like to bring to your attention to the current challenges facing our specialty. Please permit me to categorize the challenges as external or internal. External challenges such as reimbursements for cardiac surgeons, competition issues from cardiologists, litigations, and insurance cover have been discussed elaborately in many of our forums. My predecessor,

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Dr. Kunal Sarkar, and many other surgeons have spoken at length and dwelt in detail on the matter of cardiological interventions versus CABG for coronary artery diseases. Hence, I would like to restrict myself to discuss the internal challenges facing our specialty which if not addressed well and early, may render us irrelevant in the years to come. The internal challenges as I see it are (1) data collection and reporting, (2) how to attract the “Brightest and the Best” to our specialty, (3) how we can improve the quality of our training programs, and (4) what next? Can we provide a platform to make our younger surgeons of tomorrow better than what we are today…? We all recognize that data is important today. But, we do not have any meaningful data about the practice of the specialty in our country, to present or analyze as an association. At best, we can make sketchy guesses. Unfortunately, this is regarded as no one’s baby! There is a periodic upsurge in trying to pool in data as our meetings approach, and after the event… the enthusiasm wanes and wanes till the next meeting. The net result is that…the third largest English speaking association of cardiovascular and thoracic surgeons in the world doing some of the largest volumes of surgery have no data to speak of and are… pushovers in any international meeting! This is most saddening. We need data as you all know, for scientific analysis, best care practices, clinical research for audit, and quality control. If we do not quickly develop a credible system in place, I am afraid the burgeoning insurance companies and the government will compel us to do so to our own peril. The database needs to be simple, web based, and smartphone friendly. Confidentiality and all legalities need to be taken care of. We need a database center which is supervised whole time by a senior CVT surgeon with staff preferably retired and dedicated to this matter only. The tenure should be about 5 years, with the process not being affected by changes in office bearers. A step in this direction has been taken today with the launch of our database. It needs our support, cooperation, and feeding of accurate data to make it succeed. Constructive criticisms and suggestions from members needs to be provided and heeded to, to enhance the utility of the database; as the saying goes, “you reap what you sow”. Coming to the next three points that I wished to dwell on, I have titled my address to cover all three aspects—The Trainer, the Trainee, and the Trained— with emphasis on mentorship for the future of our specialty. Training in CVT surgery is at a crossroads in India. There is a general consensus of opinion amongst us that training is suboptimal for various reasons, and has scaled down for the worse with ensuing years. Coupled with this, we also find that CVTS as a specialty is not being chosen as a first choice by

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post graduates, and many training positions are going vacant even in established institutions. This brings us to three questions: (1) Why are we not attracting the “Brightest & the Best”? (2) Do we need to revamp our training practices in keeping with the changing times, demands, and generational shifts?, and (3) What are the remedies for the future? For one, we all know that the training and apprenticeship to become a cardiovascular surgeon is long and ardous and ranges from 12–13 years after MBBS, which includes post MCh/DNB training, before a trainee becoming a confident independent surgeon with subspecialization skills. Associated with this, the issue of again writing competitive exams for post doctoral courses, the uncertainty of settling down early, and modest reimbursements compared to other professions, has made the specialty unattractive to most post graduate aspirants. However, with proper counseling and provision of opportunities, these perceptions could be changed. One of the reasons for not kindling interest in CVT surgery is the fear and foreboding factor prevalent during undergraduation. The undergraduates are not well informed about the specialty, or exposed to it, barring a few lectures taken very casually by one of the CVTS staff members if “time permits.” I feel this interaction should be taken seriously, made more appealing, attractive, and positive to the undergraduate and kindle interest to consider taking up CVT surgery as his/her chosen specialty in the future. We also should ensure that they are rotated in the specialty so that the fear factor and misconceptions are removed. Hence, some of our efforts should be to increase and improve our exposure to medical students at the UG level, and also to those taking up surgery as a career…,i.e., those who are doing post graduation in general surgery and rotating in CVT Surgery. The latter should be exposed to, and an interest created, and even made to do some simple procedures to emphasize this. In effect, we will need to climb down the high pedestal, and make efforts to showcase CVT surgery as a vibrant, dynamic, and a less foreboding specialty for undergraduates and to the surgical trainees. We should also take measures to emphasize that it is not beyond bounds for them to visit and see for themselves. IACTS could take the lead in sponsoring a month-long summer break for interested undergraduates to spend a month in a CVTS unit of their choice, buddying with the resident staff. This will serve to acquaint themselves about the specialty and learn more about it. AATS, I am informed, has begun this with good patronage and enthusiasm among the undergraduates. Our current training encompasses didactic and non didactic teaching of concepts and applied basics with reference to CVT surgery. In general, Specialty skills are allowed to be self learned by the trainees and more emphasis is on theory rather than a balance of theory with surgical skill development in most centers. There is also more emphasis on being a clinical surgeon rather than concomitantly developing attributes of being a researcher too. These have to be considered and

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addressed by our colleagues supervising training of young surgeons. In India, we have a long cherished and exalted gurushishya relationship as eloquently portrayed by the Geeta Upadesha in the Bhagvad Geeta. “Teachers open the doors but you must enter yourself,” as the saying goes. The trainer plays a big role in creating interest and sustaining it. They have to be “Role Models” interacting with young minds, approachable to any level of trainees and should fire the latter’s imagination and nurture their inquisitiveness. Vibrations in the training unit has to be positive and constant “food for thought” needs to be provided to the younger colleagues. Newer methods of imparting knowledge and skills need to be incorporated. Use of newer technologies, in keeping with changing times, appeal to the younger technology-savvy resident staff. Currently, we are finding a paucity of this environment in most training centers. Though the trainers are appointed as teachers, they are busy in their private practices leaving very little time to be spent with residents and trainees. There are no end points given to achieve, and even if there are, there is no monitoring or accountability. There are no program directors in any teaching institution who will supervise the adequacy of the training imparted. The result is that a candidate “Self Learns,” gets disgruntled, and we have a “Half Baked” product coming out of most programs. I wish to recognize the passion and efforts of one of the most dedicated teachers in recent times, Dr. Anil Tendolkar. His approach, enthusiasm, and thoughtful methods has made him one of the most loved and revered of CVTS teachers in recent times. The trainees of today are different whether we like it or not or agree or disagree. An article that appeared in one of the recent issues of the EJCTS [1] caught my eye. It deals with generational shifts. A generation is thought to be of about 25 years which is the usual age that a lady bears a child. Pre-boomers who were born in the period 1925–1944 are generally retired and inactive currently. The Baby Boomers who were born after the War is the generation who are in positions of authority now, and their progeny are the Generation Y... are the ones who are currently applying for resident positions. Generation X is the interim generation between the former two. It then becomes important to appreciate the generational differences, and see whether a change in attitudes is necessary to appeal and get the best out of the current workforce of Generation Y! If we pause to see the behavioral differences of the three generations mentioned earlier… Baby Boomers are conformists and augment education with textbooks!, celebrate individualism and, hence, called the “me” generation. Generation X are more relaxed in approach, to work, and consider their job to make a living and

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achieve personal goals, focus on the Internet to supplement their knowledge. They need to be impressed by their bosses independently of the latter’s titles or years of experience. Also termed as the “We Differ” generation. The current generation of trainees belong to the Generation Y. They are sophisticated, technologically savvy, able to harness all the functions of the smartphone, well provided for from childhood with many having double income parents, have experienced a childhood based on a team-based approach, with credit for victories and achievements being shared too… I win, you win… also called a “trophy” generation! Essentially, there were no losers in competitions! They are able to manage professional and personal lives with smartphones and are adept at informal communication styles. Work-life balance and remote working are important in their lives. Hence, with this kind of generation shifts that we are seeing, do we need to revamp our training protocols…? I would emphatically say a big “YES!” to keep up the interest in CVT surgery by the next generation. What do we need to do to rekindle the interest in the new generation of residents? Embrace technology and incorporate the same in our training protocols. Allow them to multitask in lieu of rigid stereotypes, adopt a team-based approach, let them achieve a reasonable work-life balance and develop an informal hierarchy characterized by openness where issues could be addressed without fear, and feedbacks encouraged. Currently we face many bottlenecks in our efforts to effect a change. To name a few, selection of candidates is not in our hands. We take what we get. Training programs and syllabi are fixed by statutory bodies. IACTS is only an advisory body whose recommendations could be vetoed. In general, there is a pervasive feeling that the quality of training of our MCh and DNB candidates is declining, the factors being many. So what do our trainees do after they have finished their “training program” and obtained the necessary qualification? Train again as their exposure and training is inadequate…! They look out for jobs in a center to gain some operative experience and try to subspecialize if possible. “Hang on” in a center for a period of time and endeavor to go overseas. The whole process is a hit and miss affair and is not organized currently even if the candidate wishes to pursue a subspecialty. So, what is the solution to this problem? For, if not addressed, there will come a time when there would be no takers for CVT surgery. IACTS is the national body of CVT surgeons of India. Teaching and training are mostly concentrated in medical colleges and some private and public institutions. In all these

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centers, only basic training, albeit with lots of lacunae, is imparted. However, there are many senior and skilled surgeons in the academic and private sector outside of medical colleges, whose skills lie untapped and which could be harnessed to fill this lacuna of training. IACTS is also a scientific body, promoting scientific exchange of ideas, meetings, and has been involved in training by conducting regular CME programs for the post graduates. Its function is not much into regulation of CVTS training but plays an advisory role to the regulatory bodies. While efforts to revamp the training program needs to be pursued in the long-term, IACTS as a body could take a step further in imparting practical knowledge and surgical skills to the young surgeons… and that is, to adopt a format of mentoring the freshly qualified surgeons, with a view to giving them more refined training, and an experience that they have not been able to secure during their post doctoral courses. There is mentoring after basic training in many walks of life. It is surprising that we have not thought about this in the field of CVT surgery where a high degree of skill and judgment is required for the young surgeon to become independent and his competency is validated. Given the higher skills required to practice the various subspecialties of CVT surgery, it is time for us to have structured and mentored fellowships under the umbrella of IACTS to impart skills to the interested younger surgeons. This brings us to the distinction and differentiation between a teacher and a guru or mentor. As Paul Soderberg says: “More than mere teachers, mentors are often emancipators, freeing individuals from poor technique, clouded vision, and personal uncertainty.” To further distinguish teachers from mentors: Knowledge and Experience: A teacher has profound academic knowledge. A mentor has years of experience in the field, which he uses to guide the individual. Methods of teaching A teacher instructs. A mentor advises and allows the mentee to find his/her path & guides him/her so. Q&A A teacher answers your questions. A guru questions your answers. Responsibility A teacher takes responsibility for your growth. A guru makes you responsible for your growth Role and Influence: The main role of a teacher is to impart knowledge through instruction. However, the main role of a mentor is guidance. A teacher develops the academic knowledge of the student.

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A mentor develops the professional capacities of the mentee. So who could we consider a “Mentor” and what attributes should he or she have? A skilled peer respected surgeon with leadership skills; A towering, ethical, non controversial personality respected by all peers with integrity; Magnanimous and Have the Ability to inspire and provoke a “Thought process”; Willing to invest time in the development of the mentee; Ability to offer honest opinions and Confident of handling problems created by the mentee in the course of his/her training!!! The statement by Romain Rolland sums up the mentor’s abilities as: If a man is to shed the light of the sun upon other men, he must first of all have it within himself! Mentoring in the field of CVT Surgery is a challenging and an ardous process. It needs dedication, patience, firmness, and self belief. From the mentee’ s viewpoint, getting mentored is honing in on learnt skills under the supervision of a senior veteran surgeon, imbibing the judgment, thought process, and execution of procedures from the mentor... similar to “Learning the Tricks of the trade” and growing up from a boy or girl to a man/woman. It is a form of informal education and skill transmission that many a time leads to subspecialization. This whole process appears mandatory for the mentee, to acquire the necessary skills needed to practice the subspecialty. I see a great opportunity in this process to make a difference in assessing and establishing competency in our younger colleagues who wish to improve and or learn newer skills or wish to subspecialize. As they already have a post doctoral qualification, further qualification appears superflous, and what they require is competency-based training and further training to acquire operative skills. To sum up, this whole exercise is to make them into trained operating independent CVT surgeons. In this sphere, I feel... unshackled by constricting regulations needed to modify training programs, we could commence, peer-reviewed and peer-mentored certified courses utilizing our huge resource of very skilled and senior manpower who are distinguished members of the IACTS. This could give a unique opportunity to our younger colleagues to grow and develop themselves under the tutelage of the seniors under the umbrella of IACTS. The role of the IACTS I envisage could be mentoring, confidence building in these young surgeons, training for leadership assumption, clinical research, creation of job opportunities, accreditation of centers for mentored fellowships, and ensuring standards of these mentored fellowships to meet the standards set by our academic council and individual subcommittees. This should be a one-on-one mentored Fellowship, made special by its personal mentor-mentee relationship in contrast to many other fellowships in vogue. There could be supervised development of operative skills, thought processes, and acquisition of the nuances of the subspecialty. The mentee at the completion of

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the fellowship is certified by the mentor as a trained surgeon, in the subspecialty, under the umbrella of IACTS, and the mentor takes responsibility for the skills imparted and learnt by the mentee. I envisage that fellowships could be begun in the following areas of subspecialization: congenital heart fellowships, thoracic surgery fellowships, adult cardiac surgery fellowships, minimal access surgery, CABG (off pump), valve repair, transplant and heart failure, and aortic surgery fellowships. IACTS could also venture to conduct more value added short term courses for its members in areas such as leadership development, teaching and mentoring courses for young surgeons assuming these responsibilities, and a basic course on statistical methods used in research and publishing and its interpretation, to name a few. The academic council and its academic courses subcommittee could shoulder this responsibility and work out the specifics. The Congenital Heart Fellowships and Thoracic Surgery mentored fellowships under the IACTS have been launched this year on. The specifics on this is displayed on the IACTS website. The Congenital Heart fellowship is a 2-year mentored fellowship. The important features are the norms for appointment of a mentor by IACTS. The selection of a mentee and a minimum number of stipulated surgical procedures to be done by the mentee and time spent with the mentor before his/ her certification as “Trained” by the mentor have been prescribed. The end points envisaged for this fellowship is— that the mentee/trainee should be able to lead a team in this subspecialty, confidently approach and operate upon congenital heart cases, has grasped the concepts, and nuances to successfully practice the subspecialty, to build and lead a unit. Having dwelt on the trained and the trainers, let me offer some peans to our trainees. I believe we have a long history of the guru-shishya relationship and this has been extolled in our scriptures. It is a two-way relationship, and in the classical sense, the shishya surrenders himself to the guru to be mentored. The shishya is expected to have certain qualities and self discipline to deserve this “honor” of being accepted under the guru. Well, what are they? & & & & & & & & & &

Whole hearted commitment Inquisitive. Do not take things for granted Question, question, and question Reading in depth and not for exams only! Passionate about perfection and excellence Frequent Introspection In residency, every thing else is secondary Patience. Skills are not acquired in a day! Keep Fit Positive and optimistic frame of mind

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& & & & & &

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Plan... plan your future and have set 3–5 year goals giving you a sense of direction Visit centers. Observe as many surgeons as possible Be fearless. Everyone is human, including your mentor Do not move frequently Grow up in a group. A surgeon understands your problems like no other. Like a jigsaw puzzle, everything falls into place at the end, and your toil and efforts will pay you rich dividends.

And finally, ladies and gentlemen, the milieu for training and the training environment have also to be conducive. The quality of care delivered has to be one of excellence. CVT surgery as we all know and appreciate is a team-based specialty with each team member contributing to the success of the surgical outcomes. In a unit, we have other non medical allied healthcare professionals like physician assistants, nurses, perfusionists, CVT coordinator, ECMO/VAD specialists who work shoulder to shoulder with us. It is the surgeon to whom they look up to for decisions and ensuring excellence in outcomes. Hence, their well being and motivations becomes our responsibility too. Nurses form the backbone of care delivery. Role of Nurses are changing from Basic Roles to highly specialized ones. Factors like no career progression in clinical nursing and poor salaries are affecting their morale leading to migration towards greener pasture overseas. This talent drain is affecting the delivery of good cardiovascular nursing care particularly in niche areas like congenital heart surgery in neonates and small infants. We need to contribute to reverse this trend and retain our trained nurses, empower them as an important team player and give them a status of “Partners in Growth” as programs get more sophisticated. This improvement in their roles will directly translate to ensuring better care and outcomes Physician assistants are another cadre of health care personnel who will be playing a bigger role in the future healthcare scenario in our country. They have already begun making their presence felt in CVT units across the country. Their roles and place are still ill understood in the health care hierarchy. They are specialized skilled personnel who can multitask in the specialty of their training, in the operating rooms, performance of routine chores, database management, and also could even be ECMO specialists. I believe, that in CVT surgery, they could be useful members of the core team and be a value addition to patient care delivery. It appears that our progress will be tied to the progress of their specialty in the future. A residents forum was conceived by me in 2014 at the Trivandrum IACTS meeting. I felt this could be a forum for Residents, trainees, and fellows from all over the country to meet, to deliberate their issues and suggest changes by bringing them to the respective subcommittee and academic council’s attention. They could also use this platform to exchange

information on any matter pertaining to resident education and training, exchange notes on programs, and invite special speakers of their choice to speak on a subject of interest to them at the national meeting. A Local residents representative could be nominated who could play a role in planning this part of the program with the Sr. V.P and Scientific Committee Chair. For surgeons across the world but certainly for those practicing in India, the cost of cardiac surgeries particularly with an ever depreciating rupee is a matter of concern. Across the board, for most patients, paying for the surgeries out of their pockets is beyond their affordability. Private health insurance is sketchy and the government reimbursements do not defray the actual costs. To add more woes, private insurance companies do not cover congenital heart surgery much to the difficulty and chagrin of parents who have taken policies assuming this cover! Those with group insurance are a bit more fortunate. I have made an initial foray in bringing this to the concerned government departmental attention, but more needs to be done from the association. Affordability, competition, and numbers always serve to build pressure to artificially mark the costs down, but there is a “limit” to this before it impacts the quality of care delivered and outcomes achieved. As they say… The is no free lunch! It is only introspection, innovation, improvisation, imagination, and indigenization of care delivery with limited resources that truly reduces the cost. The bottomline is we must strive to ensure excellence in outcomes with at least sustainable costs and not slip into mediocrity by cutting corners to save on costs… as John Ruskin said: “Quality is never an accident: It is always the result of intelligent effort. The bitterness of poor quality lingers long after the sweetness of low price is forgotten.” So, friends, before I conclude, I wish to present a few thoughts and wishlists for the future of IACTS. A permanent secretariat of IACTS with all meeting and communication facilities, a small auditorium for conduction of short courses and staff, in a well-connected city with reasonable outgo from the association budget. We could develop our Mumbai Office or think about elsewhere, and a central database center to build on our initiative launched today. My other suggestion would be to form various subcommittes and working groups in the IACTS reporting to the executive committee, for specific functions, inputs, and conduct/supervision of the various courses proposed earlier. We could say we have the following subcommittees: fellowship subcommittees (CHS & TS), faculty of mentors, training and academic subcommittee, liason and editorial subcommittee (which is already functioning). I believe that this will help to widen the scope and encourage more members to participate in IACTS matters and bring in more talent and thought processes.

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I would like to thank my predecessors Dr. Bhabatosh Biswas and Dr. Kunal Sarkar for their advice and encouragement of the newer initiatives, Dr. K.N. Bhosle for having streamlined the IACTS accounts and, more recently, Dr. Hamdulay for ably taking over from Dr. Bhosle. Dr. Jayakumar, Dr. Sancheti, and Dr. Gopichand for their advice and wise counsel, My executive committee members, particularly Drs. Trushar Gajjar and Hiremath who transformed my ideas of a residents forum to a vibrant reality, and Dr. Nirmal Gupta, Dr. Surendra Agarwal, and Dr. Shantanu Pande and team for making this annual conference possible despite seemingly impossible odds.

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I have reserved my special thanks to my good old friend and confidante, Dr. S. Rajan, the current secretary of IACTS who has ushered in many “much needed” reforms in the functioning of our association in our tenure and who has been a constant source of support to many of our recent initiatives. Finally, I wish to thank all the IACTS members once again for reposing your faith in me and I fervently hope that I have met your expectations. Training and academics for our younger surgeons has always been my passion. Hence, I dedicate this address to all the future generations of trainees and young cardiovascular and thoracic surgeons of our country. I would like to conclude with two quotations specifically directed to our trainees and future mentors… 1. We can be knowledgable with other men’s knowledge… But we cannot be wise with other men’s wisdom.—Michel de Montaigne and 2. Mentoring is a brain to pick, an ear to listen, and a push in the right direction.—John C. Crosby Thank you very much.

References 1. With my old friend & colleague—Dr. S. Rajan

Venuta F. ESTS Presidential Address. Education motivation... inspiration of Generation Y. The evolution of our species. Eur J Cardiothorac Surg. 2014;46:761–6.