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Navigating the New “Flat World” of Cardiothoracic Surgery
PRESIDENTIAL ADDRESS
Navigating the New “Flat World” of Cardiothoracic Surgery Sidney Levitsky, MD Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
I
am deeply honored by your trust and faith in electing me as your President of The Society of Thoracic Surgeons (STS). I consider this past year of stewardship as being the most important position that I have had in my entire surgical career. It has been immensely satisfying to serve the Society. With our present concerns about attracting residents into our specialty, it is important to look back into our own careers to determine who were the role models that helped us along the way. In 1956 (3 years after the first open heart operation by Dr John Gibbon), when I was a freshmen medical student at the Albert Einstein College of Medicine, I responded to an advertisement by Dr Charles Ripstein, an early closed heart surgery adapter, and Dr Robert Goetz, a cardiac physiologist, who were looking for a student to build a heart-lung machine and initiate a research laboratory program to obtain surviving animals after cardiopulmonary bypass. This experience changed my focus from psychiatry to surgery and led to a senior student, surgical elective at Johns Hopkins, where fortunately for me, Dr Alfred E. Blalock assigned me to a young assistant professor, Dr David C. Sabiston, who has remained a mentor and adviser during my entire career (Fig 1). I was fortunate to obtain general surgical, cardiovascular, and general thoracic surgical residency training at the Yale-New Haven Medical Center under the influence of Drs William W.L. Glenn, the developer of the Glenn shunt, and Gustaf E. Lindskog, a pulmonary surgery pioneer (Fig 2). After military service, I joined the Clinic of Surgery at the National Institutes of Health (NIH) under Dr Andrew G. Morrow, where I learned to become a serious surgical investigator (Fig 3). I then served as a young Chief of Cardiothoracic Surgery under Dr Lloyd M. Nyhus (Fig 4) at the University of Illinois Medical Center. During the 19 years of our association, Lloyd taught me not only how to motivate and teach young surgical residents but also how to build an academic Division of Cardiothoracic Surgery. It is fitting, at this point, that I thank the more than 60 cardiothoracic surgical residents and clinical fellows that I have trained, as well as the numerous research fellows who have rotated in my laboratory. I am certain that they taught me more than I taught them. Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30 –Feb 1, 2006. Address correspondence to Dr Levitsky, Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, LMOB 2A, 110 Francis St, Boston, MA 02215; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
Sidney Levitsky, MD
On considering what topics to cover this morning, I reviewed many of the presidential speeches of my predecessors, which varied from a focus on ethics, to philosophy, history, the technical aspects of our specialty, and to frank boosterism. Rather than take one or more of these subjects, I chose what professional diplomats and political historians, dating back to Thucydides in his comments on the Peloponnesian Wars and Henry Kissinger in his outreach to Russia and China, called “Realpolitik.” This is defined as politics, as a proxy for health care, based on practical concerns rather than on theory or ethics or looking at the world as it really is rather than what we imagine it to be in “the best of all possible worlds.” So this talk will be somewhat of a polemic as I try to merge the concepts of realpolitik and the corporatization of health care as well as suggestions for coping with the rapid changes to our specialty. The theme for my talk this morning is taken from the Pulitzer Prize winning New York Times journalist, Tom Friedman’s, book The World is Flat: A Brief History of the Twenty-first Century [1]. Now, how does this book on globalization of multinational corporations, which has shrunk the world and flattened the playing field and has forced us to collaborate and compete globally, affect our world of cardiothoracic surgery? I submit that the pressures Friedman describes are part of the explanation for the fundamental changes that are underway in our profession, which we must confront if the next 50 years of cardiothoracic surgery are to see the same dynamic Ann Thorac Surg 2007;83:361–9 • 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.10.100
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Fig 1. David C. Sabiston, Jr, MD.
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medical centers and clinics in the United States and Europe for expert cardiothoracic surgical care in association with the most advanced and latest technology. However, a more recent trend is a phenomenon called medical tourism, where patients from first world countries are traveling to less-developed countries for advanced medical care. In India, medical tourism is growing at 30% per year, with annual revenue predicted to be $1.1 to $2.3 billion by 2012 [2]. In Thailand, Bumrungrad Hospital treats 350,000 foreign patients per year, with volume predicted to grow at 23% annually [personal communication, M Horowitz, Nov 2005]. Medical care costs in India and Thailand are 10% to 15% of United States costs, strangely similar to the cost of manufacturing textiles in China. For Canadian patients in a single-payer system with long waiting lists and restrictions on high-cost private hospitals, medical tourism is a rational alternative. Similarly, medical tourism also makes sense for British patients, who face prolonged waiting lists using the Na-
success and innovation in patient care as the first 50 years. A significant factor in that equation is the ever-rising cost of health care in the United States (US), which is approaching 16% of our gross domestic product. Translated into simple terms, this means that the automobile industry pays more for the health care–related costs of workers manufacturing a car than the cost of steel used to build the car. The rising cost of health care associated with legacy pension costs for retired workers and its adverse effects on our major corporations is not a topic that we can solve this morning. It is, nevertheless, “the elephant in the tent” as we look at the globalization of cardiothoracic surgery. Also unaddressed is the alleged 30% of total health care costs attributed to administrative fees associated with third-party payers and an additional alleged 30% of costs owing to defensive medicine and unnecessary, non-evidenced-based health care. Moreover, we continue to face an increasing burden of more than 46.6 million Americans (2005) who have no health insurance and frequently appear at our hospital emergency departments requiring urgent cardiothoracic surgical intervention, which is rarely compensated.
Medical Tourism Well, perhaps we have nothing to worry about. Mr Friedman tells us that as “Untouchables,” who constantly upgrade their skills, we may be safe from the ravages of globalization. In fact, he specifically addresses us as “. . . Untouchables, in my lexicon, are people whose jobs cannot be outsourced . . . knowledge workers . . . a bypass surgeon’s technique is nonfungible” [1]. Outsourcing jobs and services for American physicians is not something cardiothoracic surgeons have ever thought about. Historically, wealthy patients from second and third world countries have traveled to the major
Fig 2. William W.L. Glenn, MD (top); Gustaf E. Lindskog, MD (bottom).
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Fig 3. Andrew G. Morrow, MD.
Fig 4. Lloyd M. Nyhus, MD.
tional Health Service and very high cost private hospitals. The cost for percutaneous coronary angioplasty and coronary artery bypass grafting in Thailand is about 50% of the cost for private care in Britain [3]. Cost is the major driver for middle class patients in the United States without health insurance associated with downsizing. A 2004 article in The Washington Post [4] documents the cost differential for elective aortic valve replacement for a patient in Durham, North Carolina. The estimated costs at Durham Regional Hospital, not including the surgeon’s fees, was $50,000 to $100,000 and required a $50,000 deposit. The total costs at the Escorts Heart Institute and Research Centre in India was $10,000, and this included round-trip airfare and a side trip during recovery to the Taj Mahal. The patient was operated on by a US trained surgeon formerly on the faculty at a major US university medical center. Another example of the reality of the new flat world.
programs resulting from anticipated economic and clinical synergies that inevitably failed to appear. Perhaps, Churchill [1] was correct when he stated “To build may have to be the slow laborious tasks of years; to destroy can be the thoughtless act of a single day,” in warning us how easy it is to destroy a fragile academic medical center. Nevertheless, to survive, academic medical centers have had to adapt to corporate behavior patterns, both to keep their doors open and to maintain profit margins to sustain some semblance of teaching and academic research programs. The mantra “No Margin, No Mission” continues to echo at every academic medical center administrative meeting that I attend. Corporatization and the need for adaptive adjustment for financial survival has forced many academic medical centers to move their original mission from teaching, research, and clinical care to becoming outstanding, profitable, clinical care providers, using clinical research as a profit-center. It is rare that the institutional review board that I sit on reviews a hypothesis-driven study rather than the overflowing plate of proposals for commercial drug and device testing, all with overhead payments that contribute to the hospital’s bottom line. With
Corporatization of Health Care In an article published in The Wall Street Journal, Kleineke [5] stated that, “Many physicians are understandably threatened by this watershed in the history of medicine, this challenge to 2500 years of clinical hegemony. From unquestioned GOD to accountable production worker is a long way to fall in a few short years.” This statement is a reflection of an on-going process related to the loss of physician autonomy and the global corporatization of health care. The classic not-for-profit community hospital, whose board historically consisted of volunteers who were local eminences and pillars of the community, has given way in many instances to large corporate entities and vertically integrated organizations with a major focus on the bottom line and increasing market share. Academic medical centers have not escaped from this process of corporatization. Having survived two failed hospital mergers in the 1990s, I witnessed the disruption in clinical care as well as injury to teaching and research
Fig 5. Selecting a chief of cardiothoracic surgery. Criteria for selecting a chief of cardiothoracic surgery. (Modified from Souba WW. J Am Coll Surg 2003;197:79 – 87 [6], with permission.)
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Fig 6. Percentage growth of selected revenue sources since fiscal year 1982. United States medical school finances. (Reprinted from Krakower JY, et al, JAMA 1993;270:1085–90 [7], with permission. Copyright © 1993, American Medical Association. All rights reserved.)
behavior similar to other commercial corporations, community hospitals and academic medical centers increasingly use their profits to invest in income-generating, ambulatory health care centers, shopping malls, and drug and device companies, the latter sometimes creating conflicts of interest when clinical trials are to be performed. Corporatization and globalization have also forced us to abandon old ways of choosing leaders. This construct (Fig 5) by Dr Wiley Souba [6], which I have modified for our specialty, represents the past and the theoretic present corporate criteria for choosing a chief of cardiothoracic surgery. In the past, search committees looked for national stature, recruitment from a prominent institution, clinical competency, a research track record, and so on. At present, after paying lip service to the work of the search committee, the chief executive officer (CEO) of an academic medical center or a major community hospital may look for a candidate who has an understanding of the business of medicine, and I have added, first and foremost, is a master clinical surgeon with a potentially large referral base. Now, how have all these ideas affected cardiothoracic surgery? Many hospital CEOs and deans indulge in magical thinking when they set out to recruit a chief of cardiothoracic surgery who will ride in on a shining white charger and solve the institution’s financial mishaps. After the usual platitudes about academics, their primary concern is narrowly focused to “how to find a surgeon who will fill my beds with high paying customers?” Sometimes this involves recruiting the community surgeon with the largest private practice and best local reputation to come to the academic medical center. To overcome academic requirements, even so-called elite institutions have developed new faculty tracks, which the cognesenti label bed-filler tracks in a frantic attempt to fill their beds. We now see evidence of both realpolitik and corporatization. With costs rising faster than government support and charitable donations, since 1990, both commu-
nity and academic medical centers have developed alternative sources of income with clinical activity income (Fig 6) from physician practice plans expanding
Fig 7. Annual relative value unit (RVU) and hospital margin. Surgical contribution to hospital bottom line: not all are created equal. (CRS ⫽ colon and rectal surgery; GIS ⫽ gastrointestinal; GYN ⫽ gynecology; OMFS ⫽ oral and maxillofacial surgery; ORL ⫽ otorhinolaryngology; ORTHO ⫽ orthopedic; PLAS ⫽ plastic surgery; THOR ⫽ thoracic; TXP ⫽ transplantation; VASC ⫽ vascular.) (Reprinted from Resnick AS, et al, Ann Surg 2005;242:530 –7 [8], with permission.)
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Fig 8. Turnover of cardiothoracic residency directors (surrogate division chiefs). (Reprinted with permission from RRC [Residency Review Committee] Executive Director, ACGME [Accreditation Council for Graduate Medical Education], and TSDA [Thoracic Surgery Directors Association], January 2006.)
logarithmically [7]. After neurosurgery and transplantation, both general thoracic and cardiac surgical procedures [8] are top contributors to hospital profit margins (Fig 7). For a variety of reasons, Medicare Part A and commercial insurance companies have historically been lavish in compensating hospitals, but not surgeons, for cardiothoracic procedures. A recent attempt to change this paradigm resulted in an outpouring of lobbyist activity in Congress from the medical-industrial complex. On the other hand, this high margin provides cardiothoracic surgeons the opportunity to negotiate with hospitals for payment for services that in the past have been donated to the organization while we behaved as good corporate citizens. Although, it is against Federal Stark regulations to be paid for referring patients to a particular hospital, legal safe harbors allow surgeons to be compensated for performing certain hospital administrative functions that occupy the surgeon’s time and detract from patient income-generating activities. Corporatization has had additional downsides. The length of time that a cardiothoracic surgeon remains as chief of a division appears to diminish on an annual basis (Fig 8). Using the corporate model of setting productivity and financial profit margins as milestones in assessing leadership, many cardiothoracic chiefs have lost their jobs because they failed to increase volume and market share. Outstanding surgical quality, superior teaching programs, and basic and clinical research are often put aside as markers of success in the quest for increasing profits. In addition, rapid turnover of residency directors has had a destabilizing affect on attracting residents to our specialty. Whether the corporate need for academic cardiothoracic surgeons to be continually “pronating and supinating” in the operating room to achieve institutionally mandated financial milestones is the major cause of decreasing peer-reviewed NIH grants for cardiothoracic surgery is problematic and complex enough to deserve a separate conversation. The reality is that cardiac surgical competitive grants have significantly decreased, from 137 to 36, in the 17-year period from 1987 to 2004 (Fig 9). A recent article in the Harvard Medical School alumni
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magazine announcing the closure of a historic surgical laboratory reflects realpolitik and lends some validity to this supposition. The article highlights four major reasons for closure: (1) minimal extramural funding, (2) emphasis on clinical care, (3) unable to attract residents and faculty, and (4) no career advantage [9]; however, to be fair, it must be mentioned that some of the Harvard hospitals, such as my institution, have supported independent surgical laboratories. Basic research, hypothesis-driven clinical research, and engineering innovation are the foundation of what has made cardiothoracic surgery a cutting edge specialty; the continuous development of new operative procedures using modern technology is critical if we are to survive the new flat world. With corporatization, marketing has become the touchtone for success. For the past year, as I wake up in the morning and tune in to National Public Radio, I often hear repeated advertisements for my patients to go to different medical centers, both in Boston and throughout the country, to achieve “world class” cardiac care. I continue to be amazed that every week, a new “world class” medical center in great proximity to my medical center is rated by a self-designated, commercial consulting organization as being “number one in the region,” with accompanying ribbons and banners over the entrance to the hospital. Such institutional corporate behavior can be ethically challenging for all of us. The advertising brochures of many centers positively compare their institutional outcomes with the Society of Thoracic Surgery (STS) Database; unsaid, is how accurate these comparisons are and if they are statistically valid. Who, if anyone, has audited the institutional data? Has there been oversight to prevent gaming reflected by managing mortality and moving bad outcomes to alternative categories? In this regard, I am pleased to report that the STS Database is in the process of being audited both to satisfy National Quality Forum requirements and to raise the bar for reporting accurate outcomes. In keeping with corporatization and the need for marketing, video tapes of operative procedures, which in the past have only been used for educational purposes to
Fig 9. National Institutes of Health (RO1) cardiothoracic funding: 1987 versus 2001 and 2004. (Reprinted from Verrier, ED. J Thorac Cardiovasc Surg 2004;127:1235– 44, with permission. Also, Del Nido P [Personal Communication], January, 2006.)
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physicians, are now being shown on commercial video broadcasts by institutions to increase market share and by device and drug companies for product placement. The bar has recently been raised or lowered, depending on your attitude and position on the professionalism totem pole, by hospitals producing live streaming video of operations and posting them on the Internet to mimic the “wow factor” of reality television. Newspaper reports indicate that these methods have been successful in increasing patient referral or discouraging patients in health maintenance organizations from having complex expensive procedures, depending on how the program is pitched. The STS Guidelines for Ethical Relations With Communications Media specifically states that, “live broadcasts to the general public are to be avoided. The Society believes a possibility exists wherein participating surgeons might fail to follow proper medical procedures or might be distracted because of the media and, thereby, deprive the patient of the highest quality care.” Corporatization has even reached the professional and academic organizations and journals that we all cherish. Because of increasing member services and educational activities and the need for advocacy, specialty societies have been required to recruit professional staff to manage these complex affairs associated with legislative and regulatory bodies. To avoid unsustainable dues increases, industrial income is necessary to underwrite expenses associated with our annual meeting. The ethical challenge is to avoid subtle commercial influence and to maintain balance in the educational program. With huge amounts of money at stake associated with product development, even the top-tiered medical journals, as evidenced by recent press accounts, must be diligent to avoid publishing misleading or inaccurate data. It is important that the STS and our journal, The Annals of Thoracic Surgery, consider strengthening the “Freedom of Investigation clause” as a condition for publication, mandating that cardiothoracic surgeons performing device and pharmacologic research for presentation and subsequent publication not sign “Gag Clauses in Clinical-Trial Agreements” that inhibit or prevent the publication of negative data. In addition, therapeutic turf battles between medical specialties that are associated with physicians allied with industry make balanced educational programming by major multispecialty organizations, featuring pro and con arguments, ethically difficult when these organizations are dependent on corporate income.
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geons have extraordinary knowledge and have developed outstanding outcomes. Nick Kouchoukos agreed to lead a task force, which has resulted in two oversubscribed educational conferences and more on the way. The task force also drafted “Guidelines for Credentialing Practitioners to Perform Endovascular Stent Grafting of the Thoracic Aorta,” which is scheduled to be published simultaneously in the two major cardiothoracic surgical journals. In addition, there will be educational courses at STS University during this meeting. The next step is to set up a series of short-term fellowships so that mid-career and senior cardiac surgeons can achieve clinical endovascular “wire” competence in this rapidly emerging field. The next question is how do we manage the turf battles that will undoubtedly emerge? At the present time vascular surgeons, interventional cardiologists, and interventional radiologists all claim expertise in managing thoracic aortic aneurysms by endovascular technologies. In the best-case scenario, depending on the local hospital cultural and political situation, all or some of these specialties would care for these patients jointly. The cardiothoracic surgeon brings specialized expertise in managing the increasing number of complications associated with this emerging technology and also has the judgment that comes with decades of experience and collective wisdom in operating on the diseased thoracic aorta. Most important, the cardiothoracic surgeon has the skills to differentiate which patients are most suitable for open chest procedures compared with endovascular approaches and understands that “by possessing a hammer, the entire world is not a nail.” In the interim, therefore, it is important that we rebuild our operating rooms with hybrid functions so that we have both the radiologic and ultrasonic imaging capabilities to perform endovascular surgery and also prepare for other minimally invasive and image-guided surgical procedures that will undoubtedly be commonplace in the
Endovascular Surgery Eighteen months ago, as I was about to assume stewardship of the STS, I received a call from a colleague at a major endovascular device company informing me that they were developing a percutaneous aortic root replacement device. It was obvious that if cardiothoracic surgery didn’t get involved with this new technology, we would lose an important market segment, where cardiac sur-
Fig 10. Decreasing number of applicants to cardiothoracic surgery training programs. Circles ⫽ total number of applicants; squares ⫽ active positions available; triangles ⫽ United States medical school graduate applicants. Reprinted with permission from Workforce on Health Policy, Reform and Advocacy, STS.
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near future. In my opinion, percutaneous valve insertion and percutaneous approaches for mitral valve reconstruction should be performed in the operating room to ensure safe management of early complications associated with these emerging technologies. Cardiac surgeons have to be in the forefront of clinical evaluation of these new technologies rather than being available on a stand-by basis to manage complications. Only by mastering this new and somewhat disruptive technology will we remain players in this important emerging field and ensure safe outcomes for the patients entrusted in our care. It is also important that the STS, in partnership with the American Association for Thoracic Surgery, continues to work to provide up-to-date guidelines that clearly document recent clinical outcomes and to address complications associated with operative procedures. Some physician opinion-leader advocates who are not cardiothoracic surgeons have used surgical data that are decades old rather than recent data for comparison to champion endovascular approaches for most patients requiring thoracic aortic intervention. Obviously, in the best interests of our patients, a level playing field is necessary, which can only be obtained by objective evidenced-based data.
Resident Training During the past 3 years, program directors have noted with increasing urgency the decreasing numbers of US trained medical students and surgical residents applying to the match for thoracic surgery (Fig 10). Other surgical specialties, such as general surgery and vascular surgery, have been similarly affected. In addition, difficulty in job placement in cardiothoracic surgery has compounded the problem. Data collected by the American Association of Medical Colleges and the Government Accounting Office suggest that 35% of senior medical students in 2002 chose specialties with controllable lifestyles, and in 2003, 79%
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stated that the top consideration was geographic location and lifestyle. Dermatology, radiology, and anesthesiology appear to offer the greatest amount of time off; urban legend has it that these are the specialties attracting many of our medical students (Fig 11). To this new generation of physicians, work-life balance issues are of paramount importance as well as Tom Friedman’s reminder of describing these students as part of the “leisure-time society . . . (with) a sense of entitlement” [1]. In addition, women are increasingly entering the physician workforce and in some medical schools comprise almost 50% of graduating students. Only a small percentage of women choose surgical careers, and even a smaller fraction choose cardiothoracic surgery. In 2003, thoracic surgery and vascular surgery filled 10.2% of residency positions with women and general surgery with 25.4%. Because it is impossible for us to go back in time, it is useless for us to continually mourn the passing of “the iron-surgical resident,” and the 10-year combined training program for cardiothoracic surgery. The sociologic issues are much too complex for easy and simple answers. The American Board of Thoracic Surgery has begun to address this problem by making certification by the American Board of Surgery optional rather than mandatory. The board is also considering raising the bar on resident-required operative case volume, devising new tracks for general thoracic and congenital heart surgery, and suggesting that residency directors plan endovascular surgery programs. However, because the cardiothoracic world is becoming flat, we must accelerate adoption of these new programs. We can also restructure our thoracic surgical residencies to further decrease the amount of time required in preliminary general surgical programs. We can eliminate weak, low-volume training programs with unstable academic leadership and decrease noneducational activities disguised as clinical educational activity. We can foster educational innovation through e-learning and other new technologies. Most important, we can find ways to accommodate the women who want to have children during the course of their residencies. Finally, all residency directors have an obligation to actively assist their graduating residents in finding an appropriate job. In this regard, this STS meeting will have its first structured job fair. The STS has solicited information on open job positions and advanced clinical fellowships and arranged a private office for confidential on-site interviews to accelerate this process.
Proposed Solutions Fig 11. Weeks of practice per year, United States market, 2000. In comparison with internists who average 56 hours a week and 47.7 weeks each year in patient care activities, dermatologists spend 33% less time in patient care (42 hours per week, 45.7 weeks per year). (Modified with permission from The Medical Workforce: Physicians of The Future [copyright Sg2, LLC]. Available at: http://www.sg2. com. Accessed September 11, 2006.)
I would now like to turn to considering some futuristic solutions that might possibly assist cardiothoracic surgery in coping with the new flat world. First, I want to focus on the historical separation of medicine and surgery, which in medical school departmental organization has achieved a gospel-like quality. In 1163, the Pope banned monks from shedding blood and bloodletting, and the job was given to barbers, who designated their
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“operating rooms” by the white and red spiral design barber pole. In England, King Henry VIII formalized this merger into the Great Company of Barbers and Surgeons, which persisted until 1754, when a distinct Guild of Surgeons was recognized. On a personal basis, I love and respect my general surgical colleagues, but conferences and grand rounds on cardiomyopathies and heart failure are much more interesting than cancer of the pancreas and the latest twist and turns of performing a Whipple procedure. Despite this historical background of separation, wouldn’t it be more rational to have departments across organ or disease lines, such as cardiovascular disease and pulmonary disease, rather than contrasting pharmacologic and mechanical therapeutic approaches in the medicine/surgery paradigm, which assumes that surgeons have a limited diagnostic and therapeutic horizon? In the early 1990s, there was a movement toward single product-lines, which for the most part was rapidly abandoned as chairpersons of medicine and surgery became anxious and were reluctant to give up their respective “cash-cows.” The development of specialty hospitals such as heart hospitals or cardiovascular centers, within or attached to a major medical center, compensation models that focus on proceduralists as a separate entity, in contrast to patient visit– based physicians and the concept of disease-management practitioners, have already furthered this concept. Despite medical school and hospital corporate vested interests, physicianentrepreneurs will continue to develop new models of care that will improve efficiency and outcomes. If we are to join other disciplines in organ-based departments, it is important that we redefine ourselves. As an example, the Accreditation Council for Graduate Medical Education defines neurologic surgery as a discipline of medicine and that specialty of surgery which provides operative and nonoperative management (ie, prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems. On the other hand, thoracic surgery is very narrowly defined as encompassing the operative, perioperative, and critical care Fig 12. Evolution of The Society of Thoracic Surgeons seals: past (left, 1964) and present (right, 1994). (Courtesy of Dr W. Gerald Rainer.)
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of patients with pathologic conditions of the chest with a major focus on the operative or technical procedure. All the accumulated knowledge and experience devoted to preoperative surgical decision making as well as diagnostic workup of the patient for surgical suitability or alternative therapies appears to be missing. A few minutes ago I stated that endovascular surgery of the heart, great vessels, and aorta should be performed by thoracic surgeons as the disease manager, because we have the special skills, knowledge, and judgment to provide the full array of both open and endovascular procedures. It is imperative that we redefine ourselves and accurately describe what we do and also be certain that our thoracic surgery residency programs provide an educational curriculum that encompasses all the elements of operative and nonoperative management of cardiothoracic disease. If thoracic surgeons give up disease management, we will wind up as narrow proceduralists and others will assume leadership roles in driving the new flat world of cardiothoracic surgery. I realize that developing cardiovascular and pulmonary disease departments will not occur overnight and is a long-term strategic plan. Perhaps the first tactical step to consider is the reunification of cardiothoracic and vascular surgery. Many of the more senior members of the STS were formally trained in both cardiovascular and general thoracic surgery. In the precoronary surgery era, 40% to 60% of cases performed by a cardiovascular surgeon were vascular surgery cases. With the assistance of Dr Gerald Rainer, the Society Historian, I was able to obtain the original STS logo adopted in January 1965 (Fig 12). The peripheral vascular portion of the STS logo, exemplified by the abdominal aortic aneurysm, was changed in 1994 to the thoracic aorta as cardiac surgeons turned away from peripheral vascular surgery and focused their attention on coronary artery surgery. Fortunately, the American Board of Thoracic Surgery application has continued to document “major peripheral vascular surgery” as part of the “Major Cardiovascular Procedures Section.” Both specialties and our patients would benefit, if reunification occurred.
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Professionalism It is the indirect consequences of globalization that concern me the most. As our patients and their employers participate in the increasingly global marketplace, and as the tremendous revenue generated by our work washes through and feeds the ecosystem of the health care complex, we find that the environment in which we work is increasingly corporatized, to the detriment of the core values of selfless patient care and scientific inquiry for the betterment of mankind that drew us all to this noble profession. This the last time I will formally address you as president of this Society. I would like to encourage a new generation of women and men to climb the ladder of leadership. They should be reminded that the concept of professionalism, which even in these days of corporatization of health care and the flat world is still the very basis of the founding of organizations such as the STS, should be part of our thinking in all of our clinical activities. It is the foundation of our social contract with society in return for the exceptional privileges granted to us by society. I have always felt personally honored with patients’ and societys’ trust in allowing me to hold their hearts and lungs and their very lives in my hands on a daily basis. There are numerous definitions of professionalism; the ones that I like best have been articulated by Kenneth Ludmerer [10] of Washington University and Miles Shore [11] of Harvard Medical School, which include: ● ●
Expert knowledge as distinguished by practical skill Self-regulation
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Fiduciary responsibility to place the needs of the patient ahead of self-interest of the practitioner Altruism
It is only by adhering to these verities, will cardiothoracic surgery remain a profession while managing this “new flat world of medicine.” I am certain that cardiothoracic surgery will change, and grow and thrive, as long as we persist and maintain our capacity to adapt and innovate.
References 1. Friedman TL. The world is flat: a brief history of the twenty-first century. New York, NY: Farrar, Straus and Giroux; 2005:238, 264, 371. 2. Gentleman A. Controversy in India over medical tourism. Int Herald Trib 2005;Dec 2. 3. Price Guide. The Medical Tourist Company. Available at: http://www.themedicaltouristcompany.com/price-guide. html. Accessed May 17, 2006. 4. Lancaster J. Surgeries, side trips for medical tourists: affordable care at India’s private hospitals draws growing numbers of foreigners. Wash Post Oct 21 2004:A401. 5. Kleineke JD. Medicine’s industrial revolution. Wall St J 1995;Aug 21:A8. 6. Souba WW. The new leader: New demands in a changing, turbulent environment. J Am Coll Surg 2003;197:79 – 87. 7. Krakower JY, Jolly P, Beran R. US medical school finances. JAMA 1993;270:1085–90. 8. Resnick AS, Corrigan D, Mullen JL, Kaiser LR. Surgical contribution to hospital bottom line: not all are created equal. Ann Surg 2005;242:530 –7. 9. Harvard’s surgical research laboratory has closed its doors (1912–2001). Harvard Med Alumni Bull 2004;7:50. 10. Ludmerer KM. Instilling professionalism in medical education. JAMA 1999;282:881–2. 11. Shore MF. On the professional maturation of students at Harvard Medical School. 2003;Oct 31.
Navigating the New “Flat World” of Cardiothoracic Surgery Sidney Levitsky, MD Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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am deeply honored by your trust and faith in electing me as your President of The Society of Thoracic Surgeons (STS). I consider this past year of stewardship as being the most important position that I have had in my entire surgical career. It has been immensely satisfying to serve the Society. With our present concerns about attracting residents into our specialty, it is important to look back into our own careers to determine who were the role models that helped us along the way. In 1956 (3 years after the first open heart operation by Dr John Gibbon), when I was a freshmen medical student at the Albert Einstein College of Medicine, I responded to an advertisement by Dr Charles Ripstein, an early closed heart surgery adapter, and Dr Robert Goetz, a cardiac physiologist, who were looking for a student to build a heart-lung machine and initiate a research laboratory program to obtain surviving animals after cardiopulmonary bypass. This experience changed my focus from psychiatry to surgery and led to a senior student, surgical elective at Johns Hopkins, where fortunately for me, Dr Alfred E. Blalock assigned me to a young assistant professor, Dr David C. Sabiston, who has remained a mentor and adviser during my entire career (Fig 1). I was fortunate to obtain general surgical, cardiovascular, and general thoracic surgical residency training at the Yale-New Haven Medical Center under the influence of Drs William W.L. Glenn, the developer of the Glenn shunt, and Gustaf E. Lindskog, a pulmonary surgery pioneer (Fig 2). After military service, I joined the Clinic of Surgery at the National Institutes of Health (NIH) under Dr Andrew G. Morrow, where I learned to become a serious surgical investigator (Fig 3). I then served as a young Chief of Cardiothoracic Surgery under Dr Lloyd M. Nyhus (Fig 4) at the University of Illinois Medical Center. During the 19 years of our association, Lloyd taught me not only how to motivate and teach young surgical residents but also how to build an academic Division of Cardiothoracic Surgery. It is fitting, at this point, that I thank the more than 60 cardiothoracic surgical residents and clinical fellows that I have trained, as well as the numerous research fellows who have rotated in my laboratory. I am certain that they taught me more than I taught them. Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30 –Feb 1, 2006. Address correspondence to Dr Levitsky, Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, LMOB 2A, 110 Francis St, Boston, MA 02215; e-mail: [email protected].
© 2007 by The Society of Thoracic Surgeons Published by Elsevier Inc
Sidney Levitsky, MD
On considering what topics to cover this morning, I reviewed many of the presidential speeches of my predecessors, which varied from a focus on ethics, to philosophy, history, the technical aspects of our specialty, and to frank boosterism. Rather than take one or more of these subjects, I chose what professional diplomats and political historians, dating back to Thucydides in his comments on the Peloponnesian Wars and Henry Kissinger in his outreach to Russia and China, called “Realpolitik.” This is defined as politics, as a proxy for health care, based on practical concerns rather than on theory or ethics or looking at the world as it really is rather than what we imagine it to be in “the best of all possible worlds.” So this talk will be somewhat of a polemic as I try to merge the concepts of realpolitik and the corporatization of health care as well as suggestions for coping with the rapid changes to our specialty. The theme for my talk this morning is taken from the Pulitzer Prize winning New York Times journalist, Tom Friedman’s, book The World is Flat: A Brief History of the Twenty-first Century [1]. Now, how does this book on globalization of multinational corporations, which has shrunk the world and flattened the playing field and has forced us to collaborate and compete globally, affect our world of cardiothoracic surgery? I submit that the pressures Friedman describes are part of the explanation for the fundamental changes that are underway in our profession, which we must confront if the next 50 years of cardiothoracic surgery are to see the same dynamic Ann Thorac Surg 2007;83:361–9 • 0003-4975/07/$32.00 doi:10.1016/j.athoracsur.2006.10.100
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Fig 1. David C. Sabiston, Jr, MD.
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medical centers and clinics in the United States and Europe for expert cardiothoracic surgical care in association with the most advanced and latest technology. However, a more recent trend is a phenomenon called medical tourism, where patients from first world countries are traveling to less-developed countries for advanced medical care. In India, medical tourism is growing at 30% per year, with annual revenue predicted to be $1.1 to $2.3 billion by 2012 [2]. In Thailand, Bumrungrad Hospital treats 350,000 foreign patients per year, with volume predicted to grow at 23% annually [personal communication, M Horowitz, Nov 2005]. Medical care costs in India and Thailand are 10% to 15% of United States costs, strangely similar to the cost of manufacturing textiles in China. For Canadian patients in a single-payer system with long waiting lists and restrictions on high-cost private hospitals, medical tourism is a rational alternative. Similarly, medical tourism also makes sense for British patients, who face prolonged waiting lists using the Na-
success and innovation in patient care as the first 50 years. A significant factor in that equation is the ever-rising cost of health care in the United States (US), which is approaching 16% of our gross domestic product. Translated into simple terms, this means that the automobile industry pays more for the health care–related costs of workers manufacturing a car than the cost of steel used to build the car. The rising cost of health care associated with legacy pension costs for retired workers and its adverse effects on our major corporations is not a topic that we can solve this morning. It is, nevertheless, “the elephant in the tent” as we look at the globalization of cardiothoracic surgery. Also unaddressed is the alleged 30% of total health care costs attributed to administrative fees associated with third-party payers and an additional alleged 30% of costs owing to defensive medicine and unnecessary, non-evidenced-based health care. Moreover, we continue to face an increasing burden of more than 46.6 million Americans (2005) who have no health insurance and frequently appear at our hospital emergency departments requiring urgent cardiothoracic surgical intervention, which is rarely compensated.
Medical Tourism Well, perhaps we have nothing to worry about. Mr Friedman tells us that as “Untouchables,” who constantly upgrade their skills, we may be safe from the ravages of globalization. In fact, he specifically addresses us as “. . . Untouchables, in my lexicon, are people whose jobs cannot be outsourced . . . knowledge workers . . . a bypass surgeon’s technique is nonfungible” [1]. Outsourcing jobs and services for American physicians is not something cardiothoracic surgeons have ever thought about. Historically, wealthy patients from second and third world countries have traveled to the major
Fig 2. William W.L. Glenn, MD (top); Gustaf E. Lindskog, MD (bottom).
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Fig 3. Andrew G. Morrow, MD.
Fig 4. Lloyd M. Nyhus, MD.
tional Health Service and very high cost private hospitals. The cost for percutaneous coronary angioplasty and coronary artery bypass grafting in Thailand is about 50% of the cost for private care in Britain [3]. Cost is the major driver for middle class patients in the United States without health insurance associated with downsizing. A 2004 article in The Washington Post [4] documents the cost differential for elective aortic valve replacement for a patient in Durham, North Carolina. The estimated costs at Durham Regional Hospital, not including the surgeon’s fees, was $50,000 to $100,000 and required a $50,000 deposit. The total costs at the Escorts Heart Institute and Research Centre in India was $10,000, and this included round-trip airfare and a side trip during recovery to the Taj Mahal. The patient was operated on by a US trained surgeon formerly on the faculty at a major US university medical center. Another example of the reality of the new flat world.
programs resulting from anticipated economic and clinical synergies that inevitably failed to appear. Perhaps, Churchill [1] was correct when he stated “To build may have to be the slow laborious tasks of years; to destroy can be the thoughtless act of a single day,” in warning us how easy it is to destroy a fragile academic medical center. Nevertheless, to survive, academic medical centers have had to adapt to corporate behavior patterns, both to keep their doors open and to maintain profit margins to sustain some semblance of teaching and academic research programs. The mantra “No Margin, No Mission” continues to echo at every academic medical center administrative meeting that I attend. Corporatization and the need for adaptive adjustment for financial survival has forced many academic medical centers to move their original mission from teaching, research, and clinical care to becoming outstanding, profitable, clinical care providers, using clinical research as a profit-center. It is rare that the institutional review board that I sit on reviews a hypothesis-driven study rather than the overflowing plate of proposals for commercial drug and device testing, all with overhead payments that contribute to the hospital’s bottom line. With
Corporatization of Health Care In an article published in The Wall Street Journal, Kleineke [5] stated that, “Many physicians are understandably threatened by this watershed in the history of medicine, this challenge to 2500 years of clinical hegemony. From unquestioned GOD to accountable production worker is a long way to fall in a few short years.” This statement is a reflection of an on-going process related to the loss of physician autonomy and the global corporatization of health care. The classic not-for-profit community hospital, whose board historically consisted of volunteers who were local eminences and pillars of the community, has given way in many instances to large corporate entities and vertically integrated organizations with a major focus on the bottom line and increasing market share. Academic medical centers have not escaped from this process of corporatization. Having survived two failed hospital mergers in the 1990s, I witnessed the disruption in clinical care as well as injury to teaching and research
Fig 5. Selecting a chief of cardiothoracic surgery. Criteria for selecting a chief of cardiothoracic surgery. (Modified from Souba WW. J Am Coll Surg 2003;197:79 – 87 [6], with permission.)
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Fig 6. Percentage growth of selected revenue sources since fiscal year 1982. United States medical school finances. (Reprinted from Krakower JY, et al, JAMA 1993;270:1085–90 [7], with permission. Copyright © 1993, American Medical Association. All rights reserved.)
behavior similar to other commercial corporations, community hospitals and academic medical centers increasingly use their profits to invest in income-generating, ambulatory health care centers, shopping malls, and drug and device companies, the latter sometimes creating conflicts of interest when clinical trials are to be performed. Corporatization and globalization have also forced us to abandon old ways of choosing leaders. This construct (Fig 5) by Dr Wiley Souba [6], which I have modified for our specialty, represents the past and the theoretic present corporate criteria for choosing a chief of cardiothoracic surgery. In the past, search committees looked for national stature, recruitment from a prominent institution, clinical competency, a research track record, and so on. At present, after paying lip service to the work of the search committee, the chief executive officer (CEO) of an academic medical center or a major community hospital may look for a candidate who has an understanding of the business of medicine, and I have added, first and foremost, is a master clinical surgeon with a potentially large referral base. Now, how have all these ideas affected cardiothoracic surgery? Many hospital CEOs and deans indulge in magical thinking when they set out to recruit a chief of cardiothoracic surgery who will ride in on a shining white charger and solve the institution’s financial mishaps. After the usual platitudes about academics, their primary concern is narrowly focused to “how to find a surgeon who will fill my beds with high paying customers?” Sometimes this involves recruiting the community surgeon with the largest private practice and best local reputation to come to the academic medical center. To overcome academic requirements, even so-called elite institutions have developed new faculty tracks, which the cognesenti label bed-filler tracks in a frantic attempt to fill their beds. We now see evidence of both realpolitik and corporatization. With costs rising faster than government support and charitable donations, since 1990, both commu-
nity and academic medical centers have developed alternative sources of income with clinical activity income (Fig 6) from physician practice plans expanding
Fig 7. Annual relative value unit (RVU) and hospital margin. Surgical contribution to hospital bottom line: not all are created equal. (CRS ⫽ colon and rectal surgery; GIS ⫽ gastrointestinal; GYN ⫽ gynecology; OMFS ⫽ oral and maxillofacial surgery; ORL ⫽ otorhinolaryngology; ORTHO ⫽ orthopedic; PLAS ⫽ plastic surgery; THOR ⫽ thoracic; TXP ⫽ transplantation; VASC ⫽ vascular.) (Reprinted from Resnick AS, et al, Ann Surg 2005;242:530 –7 [8], with permission.)
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Fig 8. Turnover of cardiothoracic residency directors (surrogate division chiefs). (Reprinted with permission from RRC [Residency Review Committee] Executive Director, ACGME [Accreditation Council for Graduate Medical Education], and TSDA [Thoracic Surgery Directors Association], January 2006.)
logarithmically [7]. After neurosurgery and transplantation, both general thoracic and cardiac surgical procedures [8] are top contributors to hospital profit margins (Fig 7). For a variety of reasons, Medicare Part A and commercial insurance companies have historically been lavish in compensating hospitals, but not surgeons, for cardiothoracic procedures. A recent attempt to change this paradigm resulted in an outpouring of lobbyist activity in Congress from the medical-industrial complex. On the other hand, this high margin provides cardiothoracic surgeons the opportunity to negotiate with hospitals for payment for services that in the past have been donated to the organization while we behaved as good corporate citizens. Although, it is against Federal Stark regulations to be paid for referring patients to a particular hospital, legal safe harbors allow surgeons to be compensated for performing certain hospital administrative functions that occupy the surgeon’s time and detract from patient income-generating activities. Corporatization has had additional downsides. The length of time that a cardiothoracic surgeon remains as chief of a division appears to diminish on an annual basis (Fig 8). Using the corporate model of setting productivity and financial profit margins as milestones in assessing leadership, many cardiothoracic chiefs have lost their jobs because they failed to increase volume and market share. Outstanding surgical quality, superior teaching programs, and basic and clinical research are often put aside as markers of success in the quest for increasing profits. In addition, rapid turnover of residency directors has had a destabilizing affect on attracting residents to our specialty. Whether the corporate need for academic cardiothoracic surgeons to be continually “pronating and supinating” in the operating room to achieve institutionally mandated financial milestones is the major cause of decreasing peer-reviewed NIH grants for cardiothoracic surgery is problematic and complex enough to deserve a separate conversation. The reality is that cardiac surgical competitive grants have significantly decreased, from 137 to 36, in the 17-year period from 1987 to 2004 (Fig 9). A recent article in the Harvard Medical School alumni
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magazine announcing the closure of a historic surgical laboratory reflects realpolitik and lends some validity to this supposition. The article highlights four major reasons for closure: (1) minimal extramural funding, (2) emphasis on clinical care, (3) unable to attract residents and faculty, and (4) no career advantage [9]; however, to be fair, it must be mentioned that some of the Harvard hospitals, such as my institution, have supported independent surgical laboratories. Basic research, hypothesis-driven clinical research, and engineering innovation are the foundation of what has made cardiothoracic surgery a cutting edge specialty; the continuous development of new operative procedures using modern technology is critical if we are to survive the new flat world. With corporatization, marketing has become the touchtone for success. For the past year, as I wake up in the morning and tune in to National Public Radio, I often hear repeated advertisements for my patients to go to different medical centers, both in Boston and throughout the country, to achieve “world class” cardiac care. I continue to be amazed that every week, a new “world class” medical center in great proximity to my medical center is rated by a self-designated, commercial consulting organization as being “number one in the region,” with accompanying ribbons and banners over the entrance to the hospital. Such institutional corporate behavior can be ethically challenging for all of us. The advertising brochures of many centers positively compare their institutional outcomes with the Society of Thoracic Surgery (STS) Database; unsaid, is how accurate these comparisons are and if they are statistically valid. Who, if anyone, has audited the institutional data? Has there been oversight to prevent gaming reflected by managing mortality and moving bad outcomes to alternative categories? In this regard, I am pleased to report that the STS Database is in the process of being audited both to satisfy National Quality Forum requirements and to raise the bar for reporting accurate outcomes. In keeping with corporatization and the need for marketing, video tapes of operative procedures, which in the past have only been used for educational purposes to
Fig 9. National Institutes of Health (RO1) cardiothoracic funding: 1987 versus 2001 and 2004. (Reprinted from Verrier, ED. J Thorac Cardiovasc Surg 2004;127:1235– 44, with permission. Also, Del Nido P [Personal Communication], January, 2006.)
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physicians, are now being shown on commercial video broadcasts by institutions to increase market share and by device and drug companies for product placement. The bar has recently been raised or lowered, depending on your attitude and position on the professionalism totem pole, by hospitals producing live streaming video of operations and posting them on the Internet to mimic the “wow factor” of reality television. Newspaper reports indicate that these methods have been successful in increasing patient referral or discouraging patients in health maintenance organizations from having complex expensive procedures, depending on how the program is pitched. The STS Guidelines for Ethical Relations With Communications Media specifically states that, “live broadcasts to the general public are to be avoided. The Society believes a possibility exists wherein participating surgeons might fail to follow proper medical procedures or might be distracted because of the media and, thereby, deprive the patient of the highest quality care.” Corporatization has even reached the professional and academic organizations and journals that we all cherish. Because of increasing member services and educational activities and the need for advocacy, specialty societies have been required to recruit professional staff to manage these complex affairs associated with legislative and regulatory bodies. To avoid unsustainable dues increases, industrial income is necessary to underwrite expenses associated with our annual meeting. The ethical challenge is to avoid subtle commercial influence and to maintain balance in the educational program. With huge amounts of money at stake associated with product development, even the top-tiered medical journals, as evidenced by recent press accounts, must be diligent to avoid publishing misleading or inaccurate data. It is important that the STS and our journal, The Annals of Thoracic Surgery, consider strengthening the “Freedom of Investigation clause” as a condition for publication, mandating that cardiothoracic surgeons performing device and pharmacologic research for presentation and subsequent publication not sign “Gag Clauses in Clinical-Trial Agreements” that inhibit or prevent the publication of negative data. In addition, therapeutic turf battles between medical specialties that are associated with physicians allied with industry make balanced educational programming by major multispecialty organizations, featuring pro and con arguments, ethically difficult when these organizations are dependent on corporate income.
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geons have extraordinary knowledge and have developed outstanding outcomes. Nick Kouchoukos agreed to lead a task force, which has resulted in two oversubscribed educational conferences and more on the way. The task force also drafted “Guidelines for Credentialing Practitioners to Perform Endovascular Stent Grafting of the Thoracic Aorta,” which is scheduled to be published simultaneously in the two major cardiothoracic surgical journals. In addition, there will be educational courses at STS University during this meeting. The next step is to set up a series of short-term fellowships so that mid-career and senior cardiac surgeons can achieve clinical endovascular “wire” competence in this rapidly emerging field. The next question is how do we manage the turf battles that will undoubtedly emerge? At the present time vascular surgeons, interventional cardiologists, and interventional radiologists all claim expertise in managing thoracic aortic aneurysms by endovascular technologies. In the best-case scenario, depending on the local hospital cultural and political situation, all or some of these specialties would care for these patients jointly. The cardiothoracic surgeon brings specialized expertise in managing the increasing number of complications associated with this emerging technology and also has the judgment that comes with decades of experience and collective wisdom in operating on the diseased thoracic aorta. Most important, the cardiothoracic surgeon has the skills to differentiate which patients are most suitable for open chest procedures compared with endovascular approaches and understands that “by possessing a hammer, the entire world is not a nail.” In the interim, therefore, it is important that we rebuild our operating rooms with hybrid functions so that we have both the radiologic and ultrasonic imaging capabilities to perform endovascular surgery and also prepare for other minimally invasive and image-guided surgical procedures that will undoubtedly be commonplace in the
Endovascular Surgery Eighteen months ago, as I was about to assume stewardship of the STS, I received a call from a colleague at a major endovascular device company informing me that they were developing a percutaneous aortic root replacement device. It was obvious that if cardiothoracic surgery didn’t get involved with this new technology, we would lose an important market segment, where cardiac sur-
Fig 10. Decreasing number of applicants to cardiothoracic surgery training programs. Circles ⫽ total number of applicants; squares ⫽ active positions available; triangles ⫽ United States medical school graduate applicants. Reprinted with permission from Workforce on Health Policy, Reform and Advocacy, STS.
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near future. In my opinion, percutaneous valve insertion and percutaneous approaches for mitral valve reconstruction should be performed in the operating room to ensure safe management of early complications associated with these emerging technologies. Cardiac surgeons have to be in the forefront of clinical evaluation of these new technologies rather than being available on a stand-by basis to manage complications. Only by mastering this new and somewhat disruptive technology will we remain players in this important emerging field and ensure safe outcomes for the patients entrusted in our care. It is also important that the STS, in partnership with the American Association for Thoracic Surgery, continues to work to provide up-to-date guidelines that clearly document recent clinical outcomes and to address complications associated with operative procedures. Some physician opinion-leader advocates who are not cardiothoracic surgeons have used surgical data that are decades old rather than recent data for comparison to champion endovascular approaches for most patients requiring thoracic aortic intervention. Obviously, in the best interests of our patients, a level playing field is necessary, which can only be obtained by objective evidenced-based data.
Resident Training During the past 3 years, program directors have noted with increasing urgency the decreasing numbers of US trained medical students and surgical residents applying to the match for thoracic surgery (Fig 10). Other surgical specialties, such as general surgery and vascular surgery, have been similarly affected. In addition, difficulty in job placement in cardiothoracic surgery has compounded the problem. Data collected by the American Association of Medical Colleges and the Government Accounting Office suggest that 35% of senior medical students in 2002 chose specialties with controllable lifestyles, and in 2003, 79%
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stated that the top consideration was geographic location and lifestyle. Dermatology, radiology, and anesthesiology appear to offer the greatest amount of time off; urban legend has it that these are the specialties attracting many of our medical students (Fig 11). To this new generation of physicians, work-life balance issues are of paramount importance as well as Tom Friedman’s reminder of describing these students as part of the “leisure-time society . . . (with) a sense of entitlement” [1]. In addition, women are increasingly entering the physician workforce and in some medical schools comprise almost 50% of graduating students. Only a small percentage of women choose surgical careers, and even a smaller fraction choose cardiothoracic surgery. In 2003, thoracic surgery and vascular surgery filled 10.2% of residency positions with women and general surgery with 25.4%. Because it is impossible for us to go back in time, it is useless for us to continually mourn the passing of “the iron-surgical resident,” and the 10-year combined training program for cardiothoracic surgery. The sociologic issues are much too complex for easy and simple answers. The American Board of Thoracic Surgery has begun to address this problem by making certification by the American Board of Surgery optional rather than mandatory. The board is also considering raising the bar on resident-required operative case volume, devising new tracks for general thoracic and congenital heart surgery, and suggesting that residency directors plan endovascular surgery programs. However, because the cardiothoracic world is becoming flat, we must accelerate adoption of these new programs. We can also restructure our thoracic surgical residencies to further decrease the amount of time required in preliminary general surgical programs. We can eliminate weak, low-volume training programs with unstable academic leadership and decrease noneducational activities disguised as clinical educational activity. We can foster educational innovation through e-learning and other new technologies. Most important, we can find ways to accommodate the women who want to have children during the course of their residencies. Finally, all residency directors have an obligation to actively assist their graduating residents in finding an appropriate job. In this regard, this STS meeting will have its first structured job fair. The STS has solicited information on open job positions and advanced clinical fellowships and arranged a private office for confidential on-site interviews to accelerate this process.
Proposed Solutions Fig 11. Weeks of practice per year, United States market, 2000. In comparison with internists who average 56 hours a week and 47.7 weeks each year in patient care activities, dermatologists spend 33% less time in patient care (42 hours per week, 45.7 weeks per year). (Modified with permission from The Medical Workforce: Physicians of The Future [copyright Sg2, LLC]. Available at: http://www.sg2. com. Accessed September 11, 2006.)
I would now like to turn to considering some futuristic solutions that might possibly assist cardiothoracic surgery in coping with the new flat world. First, I want to focus on the historical separation of medicine and surgery, which in medical school departmental organization has achieved a gospel-like quality. In 1163, the Pope banned monks from shedding blood and bloodletting, and the job was given to barbers, who designated their
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“operating rooms” by the white and red spiral design barber pole. In England, King Henry VIII formalized this merger into the Great Company of Barbers and Surgeons, which persisted until 1754, when a distinct Guild of Surgeons was recognized. On a personal basis, I love and respect my general surgical colleagues, but conferences and grand rounds on cardiomyopathies and heart failure are much more interesting than cancer of the pancreas and the latest twist and turns of performing a Whipple procedure. Despite this historical background of separation, wouldn’t it be more rational to have departments across organ or disease lines, such as cardiovascular disease and pulmonary disease, rather than contrasting pharmacologic and mechanical therapeutic approaches in the medicine/surgery paradigm, which assumes that surgeons have a limited diagnostic and therapeutic horizon? In the early 1990s, there was a movement toward single product-lines, which for the most part was rapidly abandoned as chairpersons of medicine and surgery became anxious and were reluctant to give up their respective “cash-cows.” The development of specialty hospitals such as heart hospitals or cardiovascular centers, within or attached to a major medical center, compensation models that focus on proceduralists as a separate entity, in contrast to patient visit– based physicians and the concept of disease-management practitioners, have already furthered this concept. Despite medical school and hospital corporate vested interests, physicianentrepreneurs will continue to develop new models of care that will improve efficiency and outcomes. If we are to join other disciplines in organ-based departments, it is important that we redefine ourselves. As an example, the Accreditation Council for Graduate Medical Education defines neurologic surgery as a discipline of medicine and that specialty of surgery which provides operative and nonoperative management (ie, prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems. On the other hand, thoracic surgery is very narrowly defined as encompassing the operative, perioperative, and critical care Fig 12. Evolution of The Society of Thoracic Surgeons seals: past (left, 1964) and present (right, 1994). (Courtesy of Dr W. Gerald Rainer.)
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of patients with pathologic conditions of the chest with a major focus on the operative or technical procedure. All the accumulated knowledge and experience devoted to preoperative surgical decision making as well as diagnostic workup of the patient for surgical suitability or alternative therapies appears to be missing. A few minutes ago I stated that endovascular surgery of the heart, great vessels, and aorta should be performed by thoracic surgeons as the disease manager, because we have the special skills, knowledge, and judgment to provide the full array of both open and endovascular procedures. It is imperative that we redefine ourselves and accurately describe what we do and also be certain that our thoracic surgery residency programs provide an educational curriculum that encompasses all the elements of operative and nonoperative management of cardiothoracic disease. If thoracic surgeons give up disease management, we will wind up as narrow proceduralists and others will assume leadership roles in driving the new flat world of cardiothoracic surgery. I realize that developing cardiovascular and pulmonary disease departments will not occur overnight and is a long-term strategic plan. Perhaps the first tactical step to consider is the reunification of cardiothoracic and vascular surgery. Many of the more senior members of the STS were formally trained in both cardiovascular and general thoracic surgery. In the precoronary surgery era, 40% to 60% of cases performed by a cardiovascular surgeon were vascular surgery cases. With the assistance of Dr Gerald Rainer, the Society Historian, I was able to obtain the original STS logo adopted in January 1965 (Fig 12). The peripheral vascular portion of the STS logo, exemplified by the abdominal aortic aneurysm, was changed in 1994 to the thoracic aorta as cardiac surgeons turned away from peripheral vascular surgery and focused their attention on coronary artery surgery. Fortunately, the American Board of Thoracic Surgery application has continued to document “major peripheral vascular surgery” as part of the “Major Cardiovascular Procedures Section.” Both specialties and our patients would benefit, if reunification occurred.
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Professionalism It is the indirect consequences of globalization that concern me the most. As our patients and their employers participate in the increasingly global marketplace, and as the tremendous revenue generated by our work washes through and feeds the ecosystem of the health care complex, we find that the environment in which we work is increasingly corporatized, to the detriment of the core values of selfless patient care and scientific inquiry for the betterment of mankind that drew us all to this noble profession. This the last time I will formally address you as president of this Society. I would like to encourage a new generation of women and men to climb the ladder of leadership. They should be reminded that the concept of professionalism, which even in these days of corporatization of health care and the flat world is still the very basis of the founding of organizations such as the STS, should be part of our thinking in all of our clinical activities. It is the foundation of our social contract with society in return for the exceptional privileges granted to us by society. I have always felt personally honored with patients’ and societys’ trust in allowing me to hold their hearts and lungs and their very lives in my hands on a daily basis. There are numerous definitions of professionalism; the ones that I like best have been articulated by Kenneth Ludmerer [10] of Washington University and Miles Shore [11] of Harvard Medical School, which include: ● ●
Expert knowledge as distinguished by practical skill Self-regulation
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Fiduciary responsibility to place the needs of the patient ahead of self-interest of the practitioner Altruism
It is only by adhering to these verities, will cardiothoracic surgery remain a profession while managing this “new flat world of medicine.” I am certain that cardiothoracic surgery will change, and grow and thrive, as long as we persist and maintain our capacity to adapt and innovate.
References 1. Friedman TL. The world is flat: a brief history of the twenty-first century. New York, NY: Farrar, Straus and Giroux; 2005:238, 264, 371. 2. Gentleman A. Controversy in India over medical tourism. Int Herald Trib 2005;Dec 2. 3. Price Guide. The Medical Tourist Company. Available at: http://www.themedicaltouristcompany.com/price-guide. html. Accessed May 17, 2006. 4. Lancaster J. Surgeries, side trips for medical tourists: affordable care at India’s private hospitals draws growing numbers of foreigners. Wash Post Oct 21 2004:A401. 5. Kleineke JD. Medicine’s industrial revolution. Wall St J 1995;Aug 21:A8. 6. Souba WW. The new leader: New demands in a changing, turbulent environment. J Am Coll Surg 2003;197:79 – 87. 7. Krakower JY, Jolly P, Beran R. US medical school finances. JAMA 1993;270:1085–90. 8. Resnick AS, Corrigan D, Mullen JL, Kaiser LR. Surgical contribution to hospital bottom line: not all are created equal. Ann Surg 2005;242:530 –7. 9. Harvard’s surgical research laboratory has closed its doors (1912–2001). Harvard Med Alumni Bull 2004;7:50. 10. Ludmerer KM. Instilling professionalism in medical education. JAMA 1999;282:881–2. 11. Shore MF. On the professional maturation of students at Harvard Medical School. 2003;Oct 31.