Pediheart Podcast #332: A Novel Cardiology Educational Approach-Shared Learning Across The Globe

Introduction to PD Heart Podcast

[00:00] Welcome to PD Heart Pediatric Cardiology. Today my name is Dr. Robert Pass.

Host Introduction and Episode Overview

[00:20] I'm the host of this podcast. I am professor of pediatrics at the Icahn School of Medicine at Mount Sinai where I'm also the chief of pediatric cardiology. Thank you for joining me for this 332nd episode of PD Heart. I hope all enjoyed last week's co-branded episode with the SADS Foundation in which we spoke with Dr. Charles Baroul about exciting new technologies for pacing and

[00:40] children, and those with congenital heart disease. For those of you interested in electrophysiology, I'd certainly recommend you take a listen to last week's 331st 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.com. This week, we move on to the world of fellow education

Overview of the Study on Twinning Pediatric Cardiology Fellowship Programs

[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

[01:20] pediatric cardiology at Children's Health Ireland at Cremland, Dublin, Ireland, the Department of Pediatric Cardiology at Texas Children's Hospital in Houston, Texas, UCD School of Medicine in Bellfield, Dublin, Ireland, and finally, Maastricht School of Health Professions Education in Maastricht, the Netherlands. When we're done reviewing this paper, I'm thrilled to mention

[01:40] that the senior author, Dr. McMahon, will be speaking with us all the way from Dublin. Therefore, let's move straight onto 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.

Virtual Learning in Pediatric Cardiology Education

[02:00] The authors mentioned that since the COVID-19 pandemic, they have observed that there has been, to use their words, an unprecedented willingness to embrace online learning formats, 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

[02:20] 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 a didactic lecture or case presentation. Both were usually presented by a fellow at one of the two centers followed by discussion

[02:40] 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 works title and they explain that this is a collaborative model whereby two communities partner to share resources, knowledge and staffing to achieve a common goal and they describe this concept

[03:00] starting with the European Union in which member countries work together to achieve goals. They then referenced prior work showing that it was demonstrated to have benefit in low-income countries. The investigators then explained that the partnership between Texas Children's and the Dublin Group developed over a four-year period, and there's a table, Table 1, on page 581 that shows

[03:20] 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 14 pediatric cardiologists between the member Irish programs at Cremland and Royal Belfast Hospital, but 68 at Texas Children's. Texas has seven categorical

Comparing Dublin and Houston Fellowship Programs

[03:40] 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 20. The Dublin program performs roughly 450 surgeries annually and the Houston program 1000

[04:00] 150, with 650 or so catheterizations in Dublin and 1,450 in Houston. For those interested in other differences between these programs, I would as usual recommend that 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

[04:20] Two very different institutions share a number of 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 Dr. McMahon in Ireland and Dr.'s

[04:40] Penny and Alan and Texas Children. And for sure, I'm sure we will all want to hear how this actually got started. The authors explained that the desired competency of the fellows as broad medical knowledge, technical mastery, particularly an echo, and also increasing emphasis on excellent communication in challenging situations. They explained that

[05:00] were also trying to encourage critical thinking in a specialty where we often 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 explain that the goal of this study

Key Findings on Fellowship Competencies and Learning Goals

[05:20] was to evaluate the utility of the program as perceived by the trainees 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

[05:40] email and the questions asked were both closed-ended ones and open-ended. The questions 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.

[06:00] In all, the authors explained that six of the Irish fellows and 20 of the Texas children fellows were invited to participate, and in total 14 fellows, or 54% of those who were asked to participate, actually did. 71% of the fellows, or 10, were from the Texas program, while the remaining four were from Ireland. And so perhaps one of the most

[06:20] important questions. Did the fellows actually find these conferences helpful? And the answer was that 93% answered that they did with the remaining 7% 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

[06:40] the United States and Ireland, and the second highest ranked session was management of aortic atresia with VSD with normal biventricular dimensions. The majority, or 71% of the respondents, felt that the sessions highlighted areas of clinical uncertainty and practice, and spoke about how different the practices were in the different locales. In regard to

Challenges Faced by Fellows in Pediatric Cardiology Training

[07:00] 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 50% stating that it was hard to find time to do this, and the reason for this in most cases was significant clinical responsibility. About 29% or about a third were

[07:20] 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 useful to them in learning, they said that throughout their fellowship, experience in clinical practice was the

[07:40] 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 authors comment on the concept of practice variation and how differences in this were really viewed as an important aspect of learning from this, and they particularly commented on how one center was more interested

[08:00] interested 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 stenting with ductile stenting and BTT shunts as a particularly interesting one in the setting of tetralogy for the fellows.

[08:20] mentioned the notion of cognitive overload and having too much to learn and too little time and having time management issues, which I'm sure rings true for 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 it is a key

Importance of Managing Uncertainty in Clinical Decision-Making

[08:40] to success for pediatric cardiologists and they felt that these sessions adequately demonstrated this. In their discussion the authors stated 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

[09:00] a trainee. There is progressive interest in developing self-regulated adaptive learners who can think critically and manage 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

[09:20] clinical uncertainty is common. Exposure to 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

[09:40] ample time for discussion, both with their peers and with facilitators. The authors review how exposing the fellows to uncertainty in this conference and in general is important and encourages critical thinking. They reemphasize the fellows' comments regarding cognitive overload and the difficulties of balancing so much data to learn with time management of training,

[10:00] and the many responsibilities that go with that. They explained in the discussion that one of the aims 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 29% of the trainees did report that the program resulted in a research question for them and the author's

Enhancing Communication Skills for Pediatric Cardiologists

[10:20] difficulty of performing large multi-institutional studies, but reference the SVR trial as 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 56% of those asked actually responding. They also point to the fact that only two

[10:40] 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 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 pediatricians

[11:00] cardiology centers in the USA and Europe. The potential for deep learning was highlighted through the use of educational sessions that centered around case-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

[11:20] 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 include embracing technology-enhanced learning, encouraging collaborative research, and international expansion. Well, I think this study is quite interesting in demonstrating how valuable it can

[11:40] 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 10 years, I have seen firsthand how working in different environments, even in the same city, broadens one's ideas regarding

Future of Collaborative Learning in Pediatric Cardiology

[12:00] management. For example, when I was a cardiology fellow, I recall a senior surgeon strongly bashing the ROS 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 of excellence for the ROS, and it would be rare in my present center to not offer that as the

[12:20] top recommendation from many forms of aortic valve disease. I've also seen how being able to contrast center approaches can be a fertile land of research questions, and my very first paper was on bulboventricular foramen resection, which was something I was told was absolutely contraindicated when I was a fellow in Boston, but then came to New York City.

[12:40] where I learned that this was in fact the preferred approach by Dr. Jan Quagobor when obstruction at that level would have hemodynamic 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 in this wonderful collaboration that we've

[13:00] reviewed this week. In the interest of time, I think we should move forward with our conversation with the works first author, Dr. 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 a Master's of Science from the University of Maastricht. He is professor of pediatric cardiology and a consultant pediatric

[13:20] 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 Dr. McMahon all the way from Dublin. Welcome Professor McMahon to Pdheart. I'm here now with Dr. Colin McMahon all the way from Dublin. Dr. McMahon

[13:40] Thank you very much for spending some time right in the middle of your workday with us on Pdheart this week. Great, Robert. Thank you very much for inviting me on to your podcast and I'm really honored to be here. It's my first ever podcast. I know of your reputation and the great work you do, so delighted to be invited and hopefully we can have an interesting conversation.

[14:00] Thank you very much. You know, as I was reading this, Dr. 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?

[14:20] That's a really great question to start with. So I guess just to give a little bit of background for 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.

[14:40] Then after being there for a few years, I moved to Texas Children's where I did fellowship. I was very lucky to work under Tim Bricker and Jeff Tobin and a wonderful group of people there. Then I also was lucky enough to work with Dr. Gava and Dr. Powell in Boston when Jim Locke was chief there.

[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 century you worked in. It was a little bit different how you managed single ventricles in Ireland compared to how you managed them in the UK compared to maybe Boston and Texas troublemakers.

[15:20] One of the ideas that arrived out of this experience of seeing different ways of managing problems was when I had the opportunity to speak to Dan Penney and Hugh Allen. I want to commend them because this would never have happened without their input. We were really looking for a way of making education.

[15:40] education more interesting and engaging learners. And 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, develop that ability to ask interesting questions and try and answer those questions.

[16:00] really sort of spun out of a conversation between Dan and myself and Hugh. And we didn't know how to do it or what to do. It sort of developed organically. Interesting. 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

[16:20] improve the fellows understanding of how to manage uncertainty in 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. You're hitting all the highlights of the article here Robert.

[16:40] 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 we've done some work on decision making even of simple congenital cardiac lesions and what becomes really clear is that they're often not

[17:00] binary black and white answers, but actually how we make decisions and what we base decisions on is often quite grey. 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.

[17:20] The other aspect of this that was really interesting is we're challenged in pediatric cardiology by having often very complex cardiac lesions in children who are very vulnerable, but we don't have large data sets or randomized controlled trials to make definitive evidence-based medical decisions.

[17:40] manage those cases. So I think that's why we were really open to this concept of uncertainty and recognizing it, admitting its existence, how we discuss around the MDT or the JCC conference, how to actually make decisions for specific lesions or something

[18:00] interested in. The concept of talking out process of thinking, the idea of maybe having artificial intelligence as maybe an assistant in decision making, all of these concepts were sort of areas that are now becoming more prevalent in how we actually make decisions.

[18:20] The uncertainty aspects we're very interested in managing, how you actually fix the uncertainties difficult. 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 discuss.

[18:40] say and Dr. McMahon, I think 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

[19:00] seeing that there's 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.

[19:20] So 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.

[19:40] So just a little example that there's certainly more than 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 in virtually every aspect of life. How did you set out to

[20:00] achieve that and do you think you were successful in improving that for the fellows? So you're hitting all the highlights here, Robert. You're asking the questions I helped you ask. So I personally think the biggest challenge is in being an effective communicator and if we can't explain to families, patients

[20:20] 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 used as doctors. And I think you can have 1,000 papers and all sorts of high-impact journals, but if you can't

[20:40] talk and deal with people and take care of people, then I think you have a problem. So many of the sessions that we have where we alternate between Texas Children's and Dublin, we may decide to discuss a topic or an interesting lesion, but we also discuss challenging cases that are anonymized.

[21:00] And that's really helpful because the fellows are driving the entire process. They present the case. We ask them to probe the questions that need to be answered and have them discuss 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 discuss issues.

[21:20] challenges in making a decision with a family. Maybe how to highlight that maybe 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 positive care approach. So, you know, these are fundamentally important areas, Robert,

[21:40] that sometimes they're overlooked a little bit in the formal educational process, the importance of effective communication. But also, humility is a really 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.

[22:00] 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 worry them, but what's actually worrying them. And most importantly, the child or the young adult or the teenager or the adult and child patient.

[22:20] 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 and what parents and patients want from the experience as a doctor-patient relationship is really important.

[22:40] 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 or patients are worried about. And then there's those older doctors we worked with over the years, the Barry Kanes, the Deathstuffs,

[23:00] who listen to families provided care for the patient and the family. And I think that's what we want to instill within our fellows, caring, pathetic doctors. 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.

[23:20] 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 can survive it and we can be jubilant about that fact. But if they need a pacemaker,

[23:40] some families that is actually worse than having to have done 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 wrong if we don't listen. We may miss some important issues for families if we don't really listen to them carefully.

[24:00] Richard? Well, I was wondering, you sort of lumped the fellows altogether in your analysis in the paper, but I just wondered if it was your impression whether this collaboration between Texas and Dublin was more useful or felt to be more useful by the American or the Irish fellows.

[24:20] 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? Well, we thought that was a very sensitive question to ask them. We're worried about answer they were given. And maybe I was worried I might get a very negative answer from both of them.

[24:40] I think if you read the paper, 93% of them found the sessions either helpful or really helpful. I think that's a really positive feedback and 7% were neutral who I think were under a lot of time pressure. My perception, Robert, is both of the groups got a lot of benefit. I think the benefit from the double

[25:00] group was to realize that such an incredible center like Dan and Hugh's Center with incredible numbers of staff and specialization and state-of-the-art facilities are doing things incredibly well. But also, as you mentioned earlier, the outcomes in Dublin patients were actually pretty good too.

[25:20] 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 they see maybe a center with

[25:40] not as much facilities or resources managing patients with good outcomes. And I think there are cultural 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.

[26:00] The other thing I thought that was really helpful for me because 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 are present in most of the sessions, our role is to facilitate discussion. It's not to run it. And the fellows

[26:20] Fellows often asked really great questions and they 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

[26:40] into this process and their insights. So I think both the 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 to the other program and actually be there in person. And then what we would really love to see is that this

[27:00] process would be replicated across different pediatric cardiology groups, maybe invite different groups to join as well. I think adding in a third group might be a good thing, particularly maybe from an LMIC country or a different culture like South America or Africa. I think there's a lot of potential to continue learning.

[27:20] The phrase we came up with, Robert, was collaborative learning. And this is a way for us to learn from each other. And I think programs have a lot to learn from each other. And I think we should be more proactive and also innovative and inventive in how we structure education.

[27:40] It doesn't have to be a tic-tac-tic board certification, a major stress on fellows, but we need to make learning enjoyable. 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.

[28:00] For me, it's wonderful to have such a great relationship with Hugh and Dan and the TCH group, but also to see the fellows evolve in their thinking and their ability to look at the patient as a human being in a holistic way and not just an underlying cardiac lesion is really fantastic here.

[28:20] Well, it 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 would 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, again, really good point to make, Robert. I think willing in the sense

[29:00] institutions that want to try something different. It's an organic process by its nature, so it has to sort of find its own way. What makes this process successful is the excellent fellows in Dublin and Texas Jones. And there are loads of amazing fellows throughout the US, but also international

[29:20] 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 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' relationship.

[29:40] initiative. It's not Dan's shoes or mine. 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 either AI or ethical issues in congenital cardiology, they put enormous effort and produced really fantastic discoveries.

[30:00] discussions around these topics. So I think engaging the fellows and giving them ownership. I think having countries with different resources is a good thing to do. I want to commend K. K. Kumar, who also has done this cross-continent discussion forum where they present interesting cases. And that's a brilliant

[30:20] initiative as well. So I think having countries from affluent well resource centers and maybe LMIC countries or countries with maybe lesser resources or different resources is also another good way of doing it. But I think the most important thing, Robert, just to sort of look at the overall success is people who are excited

[30:40] by education, committed to it, who want to bring holistic education to their fellows and then who are willing to let the fellows drive the process. That's what I would 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 together

[31:00] 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, Dr. McMahon, with this wonderful 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 fellow

[31:20] 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. Robert, it was an absolute pleasure and thank you very much. Great pleasure. Well, I know that most listening to Dr. McMahon will have found many points he made to be quite important.

[31:40] thought his comments about how the joint conferences resulted in an improvement of awareness of uncertainty and decision-making to be quite important. Making a good decision in a time of uncertainty is a very difficult skill and one we're all tasked with as pediatric cardiologists and so anything aimed at improving this is clearly a value. I also felt

[32:00] at 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, understanding, and compassion for our patients.

[32:20] 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 Dr. McMahon for his wise comments and time this week. To conclude this 332nd episode of Pedy Heart Pediatric Cardiology Today with Dr. Colin McMahon.

[32:40] man all the way from Dublin. We take a trip back in time to the 20th century to hear one of the great Italian metosopranos of all time, the spectacular Fiorenza Cosotto. Cosotto was born in Crescentino, Italy and studied singing in Turin. She made her debut in opera at La Scala in 1957 and she went

[33:00] onto a very long career, singing major roles in both the 1960s and 70s, and she sang at all of the major opera houses throughout the world, including over 148 performances of the Metropolitan Opera. Today we hear her singing the dramatic Voila Subhite from the great one-act opera of Mascane, entitled Cavaleria Rosas

[33:20] Thank you for joining me for this episode and thanks once again to Dr. McMahon. I hope all have a good week ahead.