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Send to a FriendWhen the two individuals first met in 1981 in Korea, it could never be imagined how various factors and forces in the region would draw them together in a scientific publishing endeavor. One was a cardiovascular surgeon newly returned from training in the USA, the other a young American heart valve salesman starting a career in Asia. A local Korean distributor introduced them so that they could discuss the merits of a leading valve. At the 1983 Congress on Thoracic & CV Surgery held in Seoul they continued a dialogue on the development of cardiac surgery in the region. Mutual respect and friendship ensued. One thing was certain, both were devoted to and interested in the future progress of cardiac surgery in Asia, albeit then from different perspectives.
They corresponded by letter and meetings occurred over the next 10 years as the salesman had progressed to the point of starting an Asian heart valve company based in Singapore, and the surgeon continued operating, employing knowledge acquired during training abroad and skills developed locally. The salesman wrote and circulated a newsletter for surgeons and colleagues covering events and news from Asian centers as a means of maintaining valuable past contacts as he traveled widely.
The surgeon operated, published articles and learned new techniques. At a dinner in Korea early in 1991, they met once again, and a question was raised: "Why not a cardiac journal for Asia?" It was difficult at the time for Asian papers to be accepted in the established Western journals due to improper use of English, limited clinical follow-up, and the lack of perseverance to ensure publishing standards were met. Initial funding was secured (yes, from the same Korean distributor), a company formed, an editorial board chosen and a call for papers announced. They knew key objectives would be to work towards best practices with top USA and European journals, to encourage original papers from local centers, and to set high standards for the peer review process over time so that papers published in their journal would also be accepted in those more established.
Where is this "tale" headed one might ask? In March 1993, the first issue of the Asian Cardiovascular & Thoracic Annals was published and the region finally had a scientific journal for its growing legions of cardiac surgeons. It was not very good but it certainly was a beginning and a means of quantifying and qualifying results throughout Asia. It also was intended to serve as a communication vehicle and "rallying point", enabling surgeons to learn what colleagues were doing in their own centers by reading and commenting on papers in the journal.
Fast forward to year 2001 and the Asian Annals is poised to join its established Western counterparts on the CTSNet. During the 1990s the tremendous growth in the number of cases and quality of surgery undertaken by Asian surgeons had been nothing short of phenomenal. New public and private heart centers opened on almost a monthly basis throughout the region as governments came to grips with the problem of heart disease faced by burgeoning populations. Western dietary influences, a significant increase in smoking, stresses associated with rapid economic development, and genetic factors all began to play a role in the dramatic increased caseloads Asian surgeons encountered. In fact, a recent survey of heart surgery done in 1999 covering Japan, Korea, Greater China, India, Pakistan and the 10 countries comprising ASEAN (Association of South East Asian Nations) estimated that close to 150,000 procedures are currently being performed. In 1980, the number was under 30,000. This, of course, reflects only the "tip of the iceberg," for, with a combined population of over 2.8 billion, the region could easily undertake 5 to 6 times that number of operations.
Financial limitations obviously played a factor in any ratio disparity as compared to the West. Public hospitals in India, for example, have waiting lists in years, not weeks, while more private hospitals open each year to address the needs of those fortunate enough to be able to afford the cost of surgery. Surgeons there perform close to 40,000 cardiac cases a year in about 90 institutions. Similar situations exist in many of the less developed countries as governments try to cope with the growing scourge of heart disease. China with a population of 1.2 billion currently performs close to 50,000 operations, but this figure could easily approach 1 million procedures if operative help was within the financial reach of the vast majority of the population, and if scores of new centers were built to handle the case load. The lack of properly trained surgeons and surgical support staff in sufficient numbers also contributes to the shortfall in the demand versus supply equation.
How will CTSNet play an expanded role in Asia in fostering continuing improvement in the treatment of heart disease?
In our opinion, the first tangible benefit of the Website is the fact it offers an electronic venue where all Asian physicians can go for current information on their specialties. Starting in the mid to late 1960s and continuing through the 1970s and 80s, visiting teams of Western doctors and nurses traveled to the far corners of Asia, teaching their eager Asian colleagues accepted techniques, introducing new implants and devices, and providing a sounding board for the surgeons and physicians as a means for them to evaluate progress within their local environment. Of course, Asian surgeons also traveled abroad to Western centers in Australia, New Zealand, America, and Europe, besides those who went to Japan for in-depth training in cardiac surgery. Medical schools in Asia were established and began to offer programs in the field as it became obvious the problem of heart disease could not be addressed without a coordinated, concerted, and directed approach to prepare its own doctors for the huge task ahead.
Interconnecting forms of communication had been slow in Asia, for one must remember when cardiac surgery began it was before the era of low cost telephone service, Fax, e-mail and internet access. Telex was the main form of "instant" communication. Western journals took months to arrive, so a lag time always existed for keeping up with advancements in the field unless the center was fortunate enough to receive a visit from a foreign entourage. Subsequent contacts were limited to correspondence from colleagues encountered on the training visits inside and out of Asia.
A significant step forward in improving communication and interaction among specialists came when leaders in Asian medicine decided in 1972 to form an association of thoracic and cardiovascular surgeons. Extensive, well-tested, peer-reviewed, and accepted surgical modalities were presented and discussed at their biennial meetings, and young and experienced surgeons alike felt part of an Asian initiative that offered them an excellent chance to improve their surgical skills. Western surgeons came to lecture and operate. Still, the cost of attending the meetings was a limiting factor to many in the developing countries, and two years was a long time to wait for the next meeting. Video courses in cardiac surgery came into the picture and as the Asian economies grew, more were able to travel, to learn special skills and to bring these back home.
But surgical advancements were coming quickly, and the time it took to disseminate information throughout Asia by journals remained a limiting factor in improving the state-of-the art. Postal service in Asia was slow and inconsistent, so the advent of Fax helped greatly in allowing faster, direct contact among surgeons (An article from a recent Western journal could be sent instantly to a colleague with appropriate notations from the sender). However, when Internet use became widespread in the mid 1990s it was a dramatic improvement for doctors within the region to communicate directly with associates, professors, and friends.
Accordingly, the advent of CTSNet in the late 1990s afforded doctors in Asia the unique ability to join the world community of cardiothoracic surgeons. All that was required was access to a computer with a modem and a link-up to the Internet. Comparable databases were being developed, evaluated and discussed with counterparts in the West and within the region. Similar standards for training and certification were becoming uniformly accepted as the CTSNet continued to encompass more surgeons and national societies. Clinical results were being shared and compared in a significantly faster timeframe, even permitting local surgeons to go on-line to learn on the CTSNet site just prior to tackling difficult cases.
The potential benefit of this truly worldwide CTSNet community, linked on-line, in real time, to surgeons in Asia and around the world is truly astounding. Obviously, the field of communications is rapidly changing as new information is posted and read in the far corners of the globe in an instant, even on handheld devices and telephones. Asia is ready, willing and able to fully interact with colleagues in the West on the CTSNet, and are proud to play our part in this worthwhile endeavor.