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Ann Thorac Surg 1995;59:1047-1055
© 1995 The Society of Thoracic Surgeons

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Presidential Address

"A Half-Dead Thing ...?"

Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina

	Introduction

Top Footnotes Introduction Thoracic Surgery Today The Future of Thoracic... The Practice Profession References

 
Public speeches, such as presidential addresses, have been said to ``codify a society's most fully articulated conceptions of order and disorder-and thus, its most highly developed definition of itself'' [1]. It has occurred to me that our Society, indeed the discipline of thoracic surgery, and the entire medical profession have been engaged lately in a most rigorous attempt to define ourselves in a world of increasing demand, decreasing resources, and shifting values.

In less than three decades we have seen dramatic changes in the practice of our discipline and a radical change in the public perception of who we are and what we do. This metamorphosis is well illustrated by two articles appearing in the lay press. The first came to my attention a number of years ago-it could have been 20 or more-when one of my children brought to me an article from Parade Magazine, the Sunday newspaper supplement, listing the ten most highly respected occupations in America. She was somewhat surprised-and I believe pleased-that thoracic surgery led the list. Some months ago, my wife brought to me another article, this time from the Wall Street Journal. In it, the sad story of two surgeons from Canton, Ohio, was told, recounting their salad days of building a heart program together in the local hospital, followed by an account of the ultimate collapse of their practice and the acrimony that attended their downfall.

Some might say that these two vignettes portray the story of thoracic surgery over the intervening years. From the mountaintops of our earlier existence, we have descended into the valleys of discontent and even despair, where we spend much of our time lost in the land of health care management, rather than the practice of medicine. And we devote an inordinate amount of time devising ways to mine its many slippery slopes for morsels of gold. Indeed, it was just this metaphor that led me to the title of this address: `` `A Half-Dead Thing ...'?'' There is a stanza in the Robert Service poem ``The Shooting of Dan McGrew'' that goes like this:

Were you ever out in the Great Alone When the moon was awful clear And the icy mountains hemmed you in With a silence you most could hear With only the howl of a timber wolf And you camped there in the cold A half dead thing in a stark dead world Clean mad for the muck called gold... .

You may have noticed that there is a question mark after the title of this address, for I'm not sure that thoracic surgery is truly ``a half-dead thing,'' as some would have us believe, or that we exist in a ``stark dead world, clean mad for the muck called gold.'' On the other hand, I am concerned enough about the continued existence of thoracic surgery as an important discipline of the medical profession that I have chosen this topic-that is, the state of our discipline-as the subject of my address.

If one dates the birth of a specialty by the appearance of a specific literature for that subject, then we are 100 years old. The book by Paget entitled The Surgery of the Chest [2], published in 1896, is the first text of thoracic surgery. It is best remembered because of the author's dim view of the future of cardiac surgery when he said ``Surgery of the heart has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart'' [2]. However, I look on it as demarcating the birth of our discipline. To accomplish this centenary analysis, I propose to address three themes that are central to its life: first, the people who practice thoracic surgery; second, the practice of thoracic surgery itself; and finally, the notion of our discipline as one of the learned professions. Obviously, these themes have many interconnections and overlapping boundaries, which I believe will become apparent.

Let us begin with the most important element of our discipline-the people who practice it.

	Thoracic Surgery Today

Top Footnotes Introduction Thoracic Surgery Today The Future of Thoracic... The Practice Profession References

 
The Practitioners
For an overview of our practitioners, we can go to the excellent workforce studies carried out by this Society over the years [3–6] (Lawrence Cohn, personal communication, 1995), as well as demographic data obtained from the American Board of Thoracic Surgery (personal communication, November 1994) and the National Board of Medical Specialties (personal communication, November 1994).

We are a male-dominated group, with only about 3% of our workforce made up of women. In spite of a growing number of women in medicine in general, recent residency data [7] suggest that this number may not be increasing for thoracic surgery, in that the percentage of female thoracic residents has varied from a low of 1.4% to a high of 6.4% over the last 10 years.

A relatively steady state has been reached in the production of certified thoracic surgeons, in that over the past 20 years, 141 candidates per year, on average, have been certified by the American Board of Thoracic Surgery. That average has dropped to 137 per year over the past 5 years. And, even though we are growing older as a group (Lawrence Cohn, personal communication, January 1995), it is still difficult to obtain an accurate attrition rate. Nevertheless, using data from the Board and the recent workforce study, one can estimate this figure with some accuracy (Table 1). This estimate is based on certain assumptions: (1) a constant input of 137 new surgeons each year, (2) all those who are certified practice, and (3) none of them die until they are more than 80 years of age. So, if anything, this overestimates the number of surgeons practicing. That number is slightly more than 4,700 at present and is predicted to level off at about 4,900 in 10 years. These overly generous estimates suggest that we are in a fairly stable situation regarding the number of people practicing our specialty. Whether this is the ``right'' number or not has been-and will continue to be-debated. However, with an aging population, including the postwar baby boom cohort, it is hard to make a case for drastic reduction in the number of thoracic surgeons being certified. This is particularly true if we broaden our clinical coverage to recapture some of the lost elements of our specialty.

So, to summarize, our present practitioner pool is predominantly male, slowly aging, and numerically stable. Our ranks are being replenished by intellectually superior young people who are perhaps slightly more diverse in terms of ethnicity and sex and who appear to be quite capable of carrying the torch, or manning the ramparts, depending on one's view of what the future holds for the practice of thoracic surgery.

The Practice
Let us now look at the practice of our discipline as reflected in the surgery we do in our training programs and our daily lives.

The distribution of cases that our residents perform seems appropriate, at least in terms of what they will be doing 10 years hence at the time of recertification (American Board of Thoracic Surgery, personal communication, November 1994) (Fig 1). Perhaps this correlation is serendipitous, but a large measure of credit must go to the American Board of Thoracic Surgery and Residency Review Committee for their dedicated effort to ensure well-balanced clinical training for our residents.

View larger version (27K): [in this window] [in a new window]   Fig 1. . Distribution of work load reported by thoracic surgery residents and by thoracic surgeons at recertification. (Data obtained from the American Board of Thoracic Surgery.)

This emphasis on numbers is perhaps understandable, if not wholly justifiable, in view of the fact that there are so few tangible measures for judging individuals or programs-even though no correlation can be demonstrated between number of operations performed and subsequent performance on the certifying examination [10]. Dependence on ``numerology'' as a measure of quality, of course, spills over into our lives as practitioners in the form of what I call ``credentialing by the numbers.'' If some of our associates in health care administration had their way, our professional privileges would be determined by numbers, specifically in terms of how many operations we do, with little regard for clinical outcome, case mix, or long-term economic impact.

What, then, are these numbers, as reflected in our various workforce studies conducted over the past two decades [3–6] (Lawrence Cohn, personal communication, January 1995)? Acknowledging again the shortcomings and potential inconsistencies of these studies, it is nonetheless interesting to chart change in our practices. The number of major operations performed per year per surgeon has increased rather dramatically, rising from 137 in 1985 to 249 in 1992 (Fig 2). The distribution continues to gravitate toward cardiac cases and reflects the same pattern of cases seen earlier, reported by those who are recertifying. The move to more cardiac surgery is certainly real and would seem to support the common belief that we are becoming ``cardiac'' surgeons rather than ``thoracic'' surgeons.

View larger version (17K): [in this window] [in a new window]   Fig 2. . Number of major operations performed per year per surgeon, 1976 to 1992. (Lawrence Cohn, personal communication, 1995.)

View larger version (27K): [in this window] [in a new window]   Fig 3. . Self-designated practice profile reported by thoracic surgeons in the recent workforce study. (Lawrence Cohn, personal communication, 1995.)

Summarizing our practice profile, we appear to be quite busy. We are performing more operations per year per surgeon than we did only a few years ago. The increase in the number of cardiac cases exceeds the increase in other operations. On the other hand, relatively few of us elect to limit our practices to one particular aspect of our discipline.

The Profession
Having analyzed in some detail the tangible qualities of our specialty, I would like to consider the more elusive entity that has to do with the character-for want of a better word-of our discipline. Or, put another way, ``How are we, as thoracic surgeons, doing as one of the learned professions?''

In an essay in the Journal of the History of Medicine and Allied Sciences, Tannenbaum [11] addresses the subject of the medical character of 19th century American physicians as reflected in public speeches of that time. She notes that such public expressions extolling the virtues of high moral standards within the profession served the dual purpose of elevating physicians in public esteem and creating solidarity within the profession. She points out [11] that Andrew Peabody, speaking at the Harvard Medical School commencement in 1870, enjoined the graduates saying: ``Let me speak, at the outset, of the intense importance of what you are, even more than what you know.'' This was the language of sincerity and character that included such personal attributes, qualities, and qualifications as earnestness, temperance, industry, loyalty, and humility.

Reflecting on these 19th century concepts, it is interesting to note our own ideas 100 years later regarding the personal traits deemed desirable for one entering our discipline. In a Delphi survey [12], leading thoracic surgeons and a group of newly certified practitioners of our discipline were asked to rank the personal qualities that should be emphasized in resident selection (Table 2). There was remarkable congruence in their ideas, as evidenced in the column showing the percentage of each group selecting a particular quality; for example, 77% and 83% of the members of these groups, respectively, believe that having high ethical standards is a vital quality for thoracic surgeons to possess. This suggests that good character remains an important part of our discipline's collective ethic.

As the 20th century dawned-and our discipline emerged-a change became apparent in the construction of the medical character. This was a result of the assimilation of the scientific discoveries of the late 19th century so that ``the defining core of the proper physician's task became less the exercise of judgment, and more the expert application of knowledge'' [13]. Instead of simply creating practitioners beyond moral reproach who engendered trust in their patients, the profession was asked to incorporate scientific knowledge and apply it in our practice. It was not enough for good doctors to be gentlemen or ladies; they had to be scientists as well. Not only should one meet the moral standards of the day, but one also must absorb a whole new body of abstract knowledge called the science of medicine and then apply that knowledge to heal patients. One was required to do as well as to be.

Concurrent with this redefining of the individual practitioner's character in the 19th century, there was the continuing evolution of traditional professions as we know them today. The movement began in England and spread to this country, more or less intact. We are the third- or fourth-generation offspring of the Royal College of Surgeons, founded in 1800. But, as Tom Ferguson reminded us in his eloquent presidential address to this Society [14], the Royal College is a product of the barbers and surgeons coming together as a livery company-or guild. These companies were highly structured trade organizations formed to provide mutual aid and protection from commercial competition. Doctor Ferguson told us that even the word ``guild'' had its origins in commerce, coming from the Old English word meaning ``money.''

This historical perspective supports the definition of professionalism put forward by the sociologist Andrew Abbott in his award-winning essay on the division and control of expert occupations [15]. In this work he concerns himself with the evolution and interrelations of professions, pointing out that they came into being as a means of controlling a particular universe of expert labor.

Professions traditionally have been thought of as organized bodies of experts who are products of elaborate systems of instruction. Their practitioners apply an esoteric body of knowledge to particular cases, and they allow entry into the profession only through examination and other formal requirements. Ordinarily, professional groups possess a code of ethics or behavior but, Abbott maintains, a code of ethics is usually a late development in the evolution of a particular profession, and it usually comes into being in an effort to maintain control of a professional jurisdiction. Although such efforts may be useful, Abbott believes that control is accomplished by two rather different methodologies: one stresses technique and the other, abstract knowledge. As he points out: ``Any occupation can obtain licensure (e.g., beauticians) or develop an ethics code (e.g., real estate). But only a knowledge system governed by abstraction can redefine its problems and tasks, defend them from interlopers, and seize new problems ...'' [15]. He goes on to point out that formalizing ideas without effective action-or in medicine's case, therapy-is not enough, and he observes that ``the elegant diagnostic practice of nineteenth-century medicine did not prevent people from patronizing other professions when the doctors could not cure them'' [15].

Thus, professions are built and sustained on the strength of a store of abstract knowledge and the ability to convert that knowledge into action. The absence or neglect of one or the other leaves a profession vulnerable to incursion from other professions or even nonprofessionals seeking to elevate themselves in the occupational hierarchy.

There are some obvious examples of such neglect that will make this point for thoracic surgery. The first example is those surgeons who have built their practices in such a way that they spend all day every day in the operating room. They are frequently our most technically gifted surgeons, who report large numbers of cases, usually with an excellent clinical outcome. They are often the pride of our profession and the favorites of the health care administrators who are so enamored with the high-volume thesis. The risk these surgeons run is over-development of the technological aspect of professionalism, leaving a void in the area of discovery, assimilation, and application of abstract knowledge. Personal participation in preoperative and postoperative care, long-term follow-up, or innovative research is sacrificed on the altar of the operating table. Case managers, intensivists, and PhDs all quickly fill the void, while the invasive cardiologists attack directly the very techniques that sustain this technologically dependent surgeon.

A second example of a type of practice that erodes our professional underpinnings is represented by those among us who become enamored with other aspects of our profession, so that clinical skills become blunted. Regardless of the successes achieved in the laboratory, or more often the administrative arena, to the extent these individuals lose their credibility as surgeons, our discipline is diminished.

A third, and more typical, example is the overworked thoracic surgeon who gives his or her patients exquisite care at all levels of their illness, but does not have the time or the inclination to be sure that all aspects of the practice of thoracic surgery are covered. Specific examples of aspects of thoracic surgery that we have lost, or are in danger of losing by this neglect, are (1) virtually all pediatric general thoracic surgery and some aspects of general thoracic surgery, (2) diagnostic bronchoscopy, (3) the treatment of thoracic trauma, (4) cardiac catheterization and its associated diagnostic and therapeutic endeavors, (5) much of arrhythmia surgery, including pacemakers and defibrillators, (6) intrathoracic vascular surgery, and, if we are not diligent, (7) thoracoscopic techniques, which may be added to the armamentarium of our colleagues in pulmonology and gastroenterology.

Clearly, the professional domain of thoracic surgery is in danger both from internal neglect and from incursions by other disciplines in medicine. At the same time, our philosophical and intellectual underpinnings are being attacked by those who would limit us to a hospital practice based principally in the operating room.

How can we meet these challenges that threaten to distort our discipline to the point that it would be unrecognizable thirty years hence? Let me take a moment to identify a few guideposts that may be useful to those who will be traveling that road. These suggestions for the future are offered in the context of the three themes we have considered: (1) the people who will be practicing thoracic surgery, (2) the practice itself, and (3) the discipline as a profession. As noted earlier, the boundaries identifying these areas necessarily overlap.

	The Future of Thoracic Surgery

Top Footnotes Introduction Thoracic Surgery Today The Future of Thoracic... The Practice Profession References

 
People
In considering the people who will be practicing our discipline, we must focus on the residency programs we proffer. It is clear that we continue to attract able, bright, caring, and dependable individuals to our discipline-the ``best and the brightest,'' as they say [8].

What is equally clear is that we are not entirely comfortable with the way we are educating these young surgeons [16]. At the root of this discomfort is the apparent dichotomy posed by the concepts of education and training. Although educational methods and training techniques are both legitimate elements of postgraduate programs, I do believe we are in danger of overdoing the training aspect of the process. This is manifested by the increasing dependence on numbers noted earlier. Our residents are required to undertake more and more repetitive tasks that depend on rote responses rather than reflective assessment.

So my first suggestion for change for our discipline is a fundamental, though not radical, alteration in the way we prepare our future practitioners. Such change will require our coming together with our colleagues in other branches of medicine and surgery. This coalition of disciplines can come about only when a closer bonding has been accomplished within the ranks of thoracic surgery, and, indeed, this is already occurring. The Board, the Residency Review Committee, and the Thoracic Surgery Directors Association-while having strong, independent leadership individually-are acutely aware of their interdegitating dependency in executing their responsibilities to their various constituents.

It is essential that the Directors Association foster programs that are humane in their demands and collegial in their function. Although the residents must be taught the necessary clinical skills, they also should be allowed opportunities for experiences beyond the operating room, including time to reflect on what they are experiencing. The Board, while protecting the public from incompetency, should not be so rigid as to preclude the pursuit of educationally sound but diverse pathways to certification. Similarly, the Residency Review Committee, while protecting the resident from exploitation, should not be so unbending as to preclude educational innovation and laudable diversity among programs.

Let me be specific in setting some goals for those who are responsible for preparing our future practitioners:

• Increase
  1. Quality, to more closely approach the ideals of a Graduate Medical Education program
     
  2. Time spent on Thoracic Surgery vis à vis other surgical disciplines
     
  
  
• Decrease
  1. Total years of training
     
  2. Operative numbers-``ceiling'' as well as ``floor''
     
  
  
• Maintain
  1. Balanced basic program, avoiding tracking
     
  2. Presence in major medical centers
     
  
  

There is an imperative need to improve our residency programs qualitatively. As we have seen, we are attracting first-rate individuals who deserve a residency more akin to a graduate medical education program than a technical training school. They have to be introduced to the fund of abstract knowledge that is the foundation of our discipline, and they need to be given time to assimilate it. I see that time coming from two sources. The first is a qualitative adjustment of the years spent in thoracic surgery-better use of the time the residents spend with us. The second requires a quantitative change in their residency experience before they enter thoracic surgery training. Presently, our residents take an average of 8.6 years to complete their graduate education [8]. I believe this time can be shortened and used more effectively, and I will elaborate on that idea below.

As already pointed out, the operative numbers in some instances are excessive. If we believe it is prudent to define a minimum operative experience, or a ``floor,'' then it is equally important to establish a ``ceiling'' to protect the resident from exploitation by others, or overindulgence on his or her own part.

In my view, it is imperative that we maintain a balanced basic educational program for our residents, as almost all of our graduates practice more than one aspect of our specialty. Tracking, within the residency, will lead to fragmentation, and the subsequent further division of our discipline will lead to its demise. Those who wish to emphasize a particular aspect of their practice already are being served well by the informal system of fellowships that are offered in a limited number of appropriate settings.

The number of our residency programs and the number of positions have been fairly stable for some years. Certainly, inadequate programs must be dealt with-as long as our definition of adequacy includes a consideration of diversity. I believe that concentrating the education of our residents into a few large centers would be as devastating as limiting the practice of our specialty to a handful of clinical ``factories'' whose chief claim to fame is their apparent production line–like ``efficiencies.'' Even if we are required to reduce the number of new surgeons we certify, this can be done by simply reducing the number of positions we offer, without closing a single good program. This would continue the diversity in our educational process that is so important to the vitality of the discipline, and it would maintain a presence for our specialty in the major medical educational centers.

I believe that the formal thoracic surgery residency should not extend beyond the 7 years now required. I would reorder those years to include 4 years in a preliminary, generalist-type program and 3 years in thoracic surgery and related fields. The preliminary program would be developed, implemented, and ultimately accredited by a consortium of surgical specialties pulled together by an organization such as the College or even a revamped American Council on Graduate Medical Education. It would include 1 year of thoracic experience-probably 6 months at a junior level and 6 months with more senior responsibility. At the successful completion of the program, the resident would be certified to pursue additional graduate education in one of a number of areas, eg, thoracic surgery, plastic surgery, pediatric surgery, or general surgery.

If thoracic surgery is to be pursued, then it would entail 3 additional years of study. Two years would be spent doing clinical thoracic surgery and 1 year in a related field or fields, such as cardiology, pulmonology, transplantation, or the experimental laboratory. These latter experiences would necessitate cooperation and coming together with our colleagues in cardiology, pulmonology, gastroenterology, and other disciplines. In my view, this reunion is long overdue, for not only would it be helpful in our training programs, but also it is probably essential for the future practice of our specialty.

	The Practice

Top Footnotes Introduction Thoracic Surgery Today The Future of Thoracic... The Practice Profession References

 
I say reunion with our closely related medical colleagues is essential because I believe that if we, and they, are to survive, we must become more collegial-transcending the often-adversarial relationships and especially eschewing the debilitatingly dependent relationships that sometimes have developed between the specialties over the past 20 years. Although our workforce data suggest that we have remained gratifyingly broad in many aspects of our clinical practices, we have given up much that was-and still could be-a part of our discipline.

Why has this occurred? Of course, there were a number of causes, many of which were beyond our control, but certainly at the center of this dilemma are two developments that were particularly devastating to our discipline. They appeared on the scene almost simultaneously in the 1960s. I am referring to (1) the almost overwhelming demands placed on us by the advent of coronary artery surgery and (2) the introduction of federal reimbursement for medical practice on a broad scale, ie, Medicare and Medicaid.

I am sure I will shock and dismay some of you by using such terms as ``devastating'' and ``overwhelming'' when referring to what is a large part of your daily practice. Certainly, if one did not finish residency training before 1970, it may be difficult to understand the impact of the operative treatment of coronary arterial disease on the practice of thoracic surgery. Perhaps the image may become more focused if you imagine what it would be like for you or your practice were coronary artery surgery to disappear tomorrow. We are all made a little uncomfortable by the image of such a change, and I am not suggesting that if it were to happen, it would be good for our discipline. Indeed, I believe that if bypass surgery were to disappear from our practice in 1995, it would have at least as devastating an effect as when it appeared on the scene in 1965. However, it seems to me that 30 years is long enough to have assimilated this operation into our practice in such a way that it does not control our lives professionally.

For at least 20 years, the strategy for building and maintaining a successful thoracic surgery practice has been linked to one operation: coronary artery bypass. Although the phenomenon may not be widespread as yet, we all have been saddened by seeing colleagues figuratively mortgage their professional souls to assure themselves a steady supply of such patients and the associated income they produce.

At present, we all are reassessing our practices in response to the birth of the bastard child of Medicare, that is, managed care. I would hope that as a part of this process, we will broaden our horizons and design our practice groups so that we can, once again, participate in all aspects of the care of thoracic diseases. No longer can we afford, professionally or financially, to ignore those parts of thoracic surgical practice that have been pushed into the background-or even out of our specialty-by the apparent ``demands'' of coronary artery surgery. Whether we can recapture some of these areas of interest we have forfeited is not known, but we should reach out to our colleagues in other areas of medicine and say, ``We are here, and we are interested in participating in the care of these patients.'' We must convince our counterparts in other areas of our profession that it is in the patient's best interest to work together in a global fashion rather than continue our insular practices. Too many of the present models of group or cooperative practices only encourage further isolation, because they are designed to enhance commercial efficiency and not to promote professional effectiveness. Unfortunately, at this time cost efficiency, not clinical effectiveness, is the engine that is driving all of medicine.

In the minds of many, the most efficient use of the medical workforce would be to secure the surgeon to the operating table, the cardiologist to the catheter, and the endoscopist to the scope that is currently fashionable. If we are not diligent, that will be the way of our future. Is there an alternative? Of course, no one knows for certain, but surely we must make an effort to influence this movement that presently is transporting us so helplessly into the nether lands of health care management in search of increasingly elusive nuggets of gold.

The most encouraging practice model that I have experienced, personally, is exemplified in the thoracic transplantation program as it has developed at our institution. Of the five thoracic surgeons in our group, three are involved directly in all aspects of thoracic transplantation, and the other two surgeons act as support staff when needed. Our surgeons are leading participants in the care of these patients in all areas: preoperative evaluation, postoperative management, and long-term follow-up, including endocardial biopsies and repeated bronchoscopies. This work, of course, is not done in isolation, but involves a corps of health professionals from pulmonology, cardiology, anesthesiology, radiology, and psychology, as well as people from pharmacy, social work, and nursing. Indeed, our transplant coordinators are, in many ways, the quintessence of all that can be good about so-called case managers and their role in the health delivery process.

Paralleling this practice paradigm is the necessity for continued involvement in research, both basic and applied. With the shift in federal health interests from the National Institutes of Health to the Health Care Finance Agency, private undertakings-such as our Thoracic Surgery Foundation for Research and Education-will play an increasingly important role in maintaining the professional underpinnings for our discipline.

There are, of course, other models that presently are functioning or can be imagined with very little effort. Regardless of which ones prevail, the most appealing for the health of our discipline will necessarily include two basic elements. They are (1) broadening our individual knowledge base and technical skills to include more of the various aspects of thoracic surgical research and practice and (2) collective rapprochement with our colleagues in related medical disciplines. These elements are, of course, at the heart of at least one understanding of what it means to be a practitioner of a profession. As was noted above [15], a profession depends on a knowledge system governed by abstraction accompanied by effective action, based on unique skills applied to particular cases-and thus a very customized service is rendered.

	Profession

Top Footnotes Introduction Thoracic Surgery Today The Future of Thoracic... The Practice Profession References

 
The guideposts for our practice also address our future as a profession, underscoring the social scientist's warning. But beyond the perspective of the social scientist lies a more subjective definition of what it means to be a member of one of the learned professions. This embodies the concept that compensation is independent of the actual practice of that profession. We should teach, or minister to our congregations, or practice medicine, with compensation being an almost incidental accompaniment of the practice of the profession-and our legal colleagues must hold high the importance of the fiduciary relationship with their clients, regardless of the financial consequences.

In my view, the present public unhappiness with the medical profession is a linear consequence of the extent to which we have abandoned this concept. Conflict of interest-apparent or real-has a profound influence on our doctor–patient relationship, both collectively and with individual patients. Eliminating the perception that our interests and those of our patients are in conflict because of economic considerations is perhaps the most challenging task our discipline faces.

It is not enough that our professional decisions be independent of personal financial considerations. We also must be certain that the public understands and believes that to be true. Clearly, in the mind of the lay person, the financial pendulum of medical care has swung away from professionalism toward the extreme of profiteering. Whether the physician gains financially by doing something or, conversely-because of ``gate keeping'' or ``capitation''-by keeping something from being done, the cloak of the entrepreneur does not wear well on a learned professional. We will need to shed that image by taking the potential for direct personal gain out of our professional decisions if we are to avoid the appearance of having a conflict of interest.

In addition, we must convince the public that the issues surrounding the application of malpractice laws are an essential part of health care reform that cannot be dealt with separately. Just as physicians should not be able to enhance their own financial positions because of their professional decisions, one's personal financial well-being should not be at risk and thus possibly influence one's professional decisions.

Similarly-and I see this as part of the same shadow that overlies our profession-we cannot allow ourselves to be caught between the superstructure of health care financing and our patients, where we are required to ration the benefits of our profession. This awkward position will undermine our credibility at least as badly as the profit-driven care schemes that have sullied our name in the past.

Above all, we should be seen as patient advocates, and our concerns must be congruent with those of our patients. No one else in the entire enterprise, not even patients themselves, can speak so knowledgeably or effectively to the subject of patient needs. By focusing on this aspect of the many schemes and systems that have been or will be put forward, we will avoid the stigma of appearing self-serving, and we will place the emphasis where it belongs-that is, on our patients' well being. When charting the course for thoracic surgery for the next century, we cannot let those who would measure our worth by production-line standards interject themselves in the very personal patient–doctor relationship. Medicine is a customized service that requires an intimate, one-on-one interface with individual patients. The so-called care managers overlook that fundamental element of our professional activity, ignoring the trees while trying to manage the forest.

This lack of sensitivity to the individualistic nature of good medical care is reminiscent of a vignette from World War II. It is reported that when Joseph Stalin was urging the Western allies to establish a second front in 1943, Churchill had objected on the grounds that it was too soon to invade western Europe. He said that doing so at that time would result in a great tragedy, with the loss of tens of thousands of lives. Stalin replied, ``When one man dies it is a tragedy. When thousands die it is statistics'' [17].

We, as professionals, care for individual patients, experiencing their personal triumphs and tragedies. Those who would manage the practice of medicine by uncaring numbers in the name of clinical efficiency must not be permitted to prevail. If, in charting the course for the next century of thoracic surgery, we will ask regularly, ``What is best for the patient?''-and then be guided in our actions by the response-our discipline will continue to thrive and, more importantly, so will our patients.

Let me capsulize my observations regarding our discipline as we complete our first 100 years. We have attracted outstanding people to thoracic surgery, so we have an obligation to them. We owe our residents an honest educational experience and our practitioners a fulfilling way of life. We have a practice that is rewarding, in that it offers a challenging life's work. We-you and I, the present-day leadership of our discipline-have an added challenge. We need to sustain the qualitative excellence now in our practices, resisting the forces that drive us toward a diminished role in the care of patients with thoracic diseases. And, although we are a respected profession, with a fund of abstract knowledge and the ability to apply it usefully, our credibility as learned professionals is being questioned. Conflicts of interest, both real and imagined, are coming between us and those we serve. Eliminating those conflicts is the toughest challenge we face today.

Finally, I will observe that for many years I maintained the rather naive belief that as I got older, life would become simpler-that with advancing age and increasing wisdom I would, one by one, sort out life's problems and the complexities of living would wither by the wayside. Of course, nothing could be farther from the truth. Life becomes more complicated, and if it also becomes more interesting, it is in the context of the Chinese curse: ``May you live in interesting times''; these are, if nothing else, ``interesting times'' in medicine. After thinking on this truth for some time, I have finally realized that its origins are spiritual in nature. I believe it is God's way of making it so we do not mind dying. Sometimes the complexities of life are so overwhelming that I have considered this for my epitaph:

``Hey, I'm outta here, man''

On a more serious note, I would ask you to consider the future of thoracic surgery. Is it ``a half-dead thing'' at the relatively tender age of 100, or are the reports of its demise ``greatly exaggerated''? To me, the future depends not so much on how we manage care, but more on how we manage the changes going on at this time in the world, in society, and in medicine. We must openly and energetically assess our professional lives and practices and then do something to meet the challenge of these changes.

The Society of Thoracic Surgeons is prepared to take on this challenge with you. Through it, collectively, and with individual effort by each of us, we can deal successfully with the perplexing problems that face us. By meeting these problems squarely, with our patients' interests foremost, I believe we can prevail, and our patients will continue to receive the many benefits thoracic surgery has to offer as a reinvigorated discipline of modern American medicine.

	Footnotes

Top Footnotes Introduction Thoracic Surgery Today The Future of Thoracic... The Practice Profession References

 
Presented at the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, Palm Springs, CA, Jan 30–Feb 1, 1995.

Address reprint requests to Dr Wilcox, 108 Burnett-Womack Building, CB 7065, Chapel Hill, NC 27599-7065.

	References

Top Footnotes Introduction Thoracic Surgery Today The Future of Thoracic... The Practice Profession References

 

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