Ann Thorac Surg 1996;62:613-621
© 1996 The Society of Thoracic Surgeons
Report
Strategic Directions Plan-1996
Ad Hoc Committee on Strategic Directions, The Society of Thoracic Surgeons
John R. Benfield, MD
 |
Foreword
|
|---|
Medicine is in the midst of drastic reorganization to which some observers have referred as a "Managed Care Revolution." In truth, the ongoing changes are part of an evolution. It is virtually certain that conditions in the future will be neither as bad as some people fear nor as good as others expect. It is also clear that current wisdom places great emphasis upon cost containment. It is now believed by most policy makers that the cost of care rendered by generalists is lower than the cost of specialty care. The truth of that belief remains to be evaluated.
In April 1995 the STS/AATS Government Relations Committee urged that a strategic planning retreat be held. The Council of The Society of Thoracic Surgeons (STS or The Society) agreed that this retreat should be held promptly.
In July 1995 a group of 29 thoracic surgeons and allied health care professionals were brought together to compile an action-oriented strategic plan. Five committees were assigned the following broad topics: Definition of Thoracic Surgery, Education of Thoracic Surgeons, Database and Technology Considerations, Workforce and Workplace Considerations, and Cost Containment or Reduction Pertaining to Thoracic Surgical Services. This plan will serve as a guide for The Society as it helps members serve their patients during this time of change. The results of the deliberations of the group were edited and prioritized by a representative leadership group in October and December of 1995. The definition of thoracic surgery provides a detailed description of the compo-nents of this specialty: general thoracic surgery, cardiovascular surgery for adults, and congenital heart surgery. The description encompasses such things as expected educational background and clinical competence. The suggested hospital privileges included under each of these component parts are specified.
The recommendations of the committees that focused upon education, technology, workforce, and cost reduction are brought together here in a format that identifies a series of specific goals. Each goal is followed by a suggested strategic direction or directions and an action plan or plans for pursuing the direction. The following is a summary of these goals, strategic directions, and action plans.
There is considerable overlap among the goals and strategic directions. However, these goals and directions are subject to change and adaptation over time. The overlap reflects the cohesive nature of thoracic surgery and its sensitivity to the needs of the community. This document is designed for periodic review and revision as certain goals are achieved, others prove to be unrealistic, and still others emerge.
I take this opportunity to thank the participants in the strategic planning process for their time and for the wisdom and work they contributed. There is no greater cadre of men and women than thoracic surgeons. We can be confident that the future of thoracic surgery will be at least as exciting as the past.
|
Strategic Directions Committees
|
|---|
Database Technology/Outcomes Committee
Frederick L. Grover, MD, Chairman
Richard P. Anderson, MD
Kit V. Arom, MD
Richard E. Clark, MD
Stanley W. Dziuban, Jr, MD
William C. Nugent, MD
Becky Petersen, RN
A. Laurie Shroyer, PhD
Workforce/Workplace Committee
Jack M. Matloff, MD, Co-Chairman
Lawrence H. Cohn, MD, Co-Chairman
Robert W. Emery, MD
Renee S. Hartz, MD
John E. Mayer, Jr, MD
David J. Sugarbaker, MD
Cost Containment/Reduction Committee
Richard G. Fosburg, MD, Chairman
Victor A. Ferraris, MD
Gregory L. Kay, MD
U. Scott Page, MD
Stephen K. Plume, MD
Victor F. Trastek, MD
Education Committee
Benson R. Wilcox, MD, Chairman
David B. Campbell, MD
Gordon F. Murray, MD
Mark B. Orringer, MD
Robert K. Salley, MD
Definitions Committee
John R. Benfield, MD, Chairman
Andre Duranceau, MD
L. Penfield Faber, MD
Robert A. Guyton, MD
Constantine Mavroudis, MD
|
The Definition of Thoracic Surgery
|
|---|
Thoracic surgery and its component specialties (general thoracic surgery, cardiovascular surgery for adults, congenital heart surgery) are defined herein for the purpose of assisting patients, their physicians, and third-party payers as they select thoracic surgical care.
Education and Training
Components of thoracic surgery residency include surgery for acquired heart disease, pulmonary surgery, esophageal surgery, surgery for congenital heart disease, endoscopy of the lungs and esophagus, video-assisted thoracic surgery (including thoracoscopy), and transplantation of the heart and lungs.
The purpose and goal of a thoracic surgical residency program is to advocate a comprehensive and clinically competent surgeon [1]. A thoracic surgeon must have successfully completed a 2- to 3-year approved residency in thoracic surgery after successful completion of an approved 5- to 6-year residency in general surgery. Approval is granted by the Accreditation Council on Graduate Medical Education of the American Medical Association.
The curriculum of an Accreditation Council on Graduate Medical Education approved thoracic surgical residency incorporates a broad perspective of thoracic surgical experience. This experience includes participation in the diagnosis, surgical management, postoperative intensive care, and follow-up care of patients with diseases of the chest. This involves interaction with the residents and faculty in such allied specialties as internal medicine, pediatrics, family medicine, respiratory medicine/critical care, cardiology, gastroenterology, radiology, medical oncology, infectious diseases, and radiation oncology.
Important elements of a thoracic surgical residency include personal monitoring of residents by teachers who have been certified by the American Board of Thoracic Surgery (ABTS). During residency there is gradual assumption of senior-level independent decision making by the thoracic surgery residents. The experience of thoracic surgical residents includes developing the ability to understand and to interpret current clinical and basic research publications pertinent to thoracic surgery.
Board Certification
Thoracic surgeons must currently be certified for 10-year periods by the ABTS after prerequisite certification in general surgery by the American Board of Surgery. After 10 years, thoracic surgeons whose initial certification was later than 1976 must be certified again by the ABTS.
Clinical Competence
Thoracic surgeons maintain active practices in the care of patients with surgical diseases of the chest. Each thoracic surgeon who is certified by the ABTS has been prepared to work competently in each of the component parts of thoracic surgery. Depending upon the workplace and the needs of his or her community, each thoracic surgeon may elect to practice the specialty broadly or to focus his or her attention primarily upon one of the component parts. Thoracic surgeons demonstrate continued interest in the specialty and in new developments through membership in thoracic surgery societies and associations and through attendance and participation in appropriate specialty meeting and symposia.
The intent of the following is to bring clarity to a variety of terms that have been applied to thoracic surgery and its components (general thoracic surgery, cardiovascular surgery for adults, congenital heart surgery).
|
General Thoracic Surgery
|
|---|
General thoracic surgery encompasses the factual knowledge, technical skill, and judgment required to diagnose accurately and to manage surgically diseases of the thorax (chest). The knowledge base includes, but is not limited to, diseases of the chest wall, pleura, lungs, trachea and bronchi, mediastinum, diaphragm, and esophagus. General thoracic surgery requires in-depth knowledge of pulmonary and esophageal physiology, diagnostic imaging, organ function testing, preoperative evaluation, postoperative care, critical care, trauma, basic surgical oncology, and transplantation.
Education and Training
Thoracic surgeons who specialize in general thoracic surgery will often have had their education in units that emphasize general thoracic surgery, either as part of their residency in thoracic surgery or as a supplementary educational experience.
Clinical Competence
Competency in general thoracic surgery entails the continued appropriate and skilled management of general thoracic surgical problems. This requires an active caseload of diseases of the thorax as detailed above and continued interest in the practice of general thoracic surgery as evidenced by attendance and participation in appropriate specialty meetings and symposia. Involvement in research and education is necessary wherever possible.
General thoracic surgeons are specially qualified to manage surgical complications that involve the organ systems detailed above. They are also qualified to assist in the management of pulmonary, pleural, esophageal, mediastinal, and chest wall problems that arise in the course of patient management by allied specialists in such fields as internal medicine, pediatrics, gastroenterology, medical oncology, and radiation oncology.
Hospital Privileges
General thoracic surgery includes the following surgical procedures in both children and adults:
- Operations involving resection, reconstruction, repair, and biopsy of the lung.
- Operations involving the chest wall and pleura. This includes resection and reconstruction of the chest wall for neoplasms, pleurectomy, decortication, drainage and resection of empyema, thoracoplasty, and repair of pectus excavatum and pectus carinatum and other chest wall deformities. It also includes the management of traumatic chest wall instability.
- Operations involving resection, reconstruction, and repair of the trachea and bronchi for neoplasms, strictures, and trauma.
- Operations involving resection, reconstruction, and repair of the esophagus, including laparoscopic or thoracoscopic fundoplication and myotomy.
- Operations involving resection, reconstruction, and repair of the diaphragm.
- Operations involving the mediastinum, including biopsy and resection of neoplasms, drainage of infections, mediastinal lymphadenectomy, mediastinotomy, and mediastinoscopy.
- Operations of the pericardium involving resection, reconstruction, and drainage.
- Video-assisted thoracic surgical procedures of the thorax.
- Endoscopic procedures of the tracheobronchial tree and esophagus using both the flexible and rigid scopes and instruments.
- Operations for biopsy of the cervical, mediastinal, and axillary lymph nodes.
- Operations on the thoracic sympathetic nerves.
- Operations to correct abnormalities of the thoracic outlet.
- Operations necessary for airway control including tracheostomy and tracheal intubation.
- Operations for management of pleural space problems, including thoracentesis, tube thoracostomy, and pleural-peritoneal shunting for pleural effusion and management of pneumothorax from bullous disease and trauma.
- Operations to provide exposure for thoracic spine surgery.
- All operations incidental to the performance of the above operative procedures.
- Critical care management and procedures including placement of central venous lines, Swan-Ganz catheters, arterial lines, and pacemaker leads; ventilator management; and total enteral and parenteral nutrition management.
|
Cardiovascular Surgery in Adults
|
|---|
Adult cardiovascular surgery encompasses the factual knowledge, technical skill, and judgment required to diagnose accurately and to manage surgically diseases of the heart and intrathoracic vascular system. This knowledge base includes, but is not limited to, diseases of the heart, the pericardium, the aorta, the innominate and subclavian arteries, the superior and inferior venae cavae, and the pulmonary arteries and veins. The practice of cardiovascular surgery for adults requires in-depth knowledge of cardiac and circulatory physiology, cardiac and vascular imaging techniques, cardiac catheterization, echocardiography, preoperative evaluation and risk assessment, postoperative care including critical care, trauma, transplantation, and transplantation immunology.
Clinical Competence
Competency in cardiovascular surgery in adults entails the continued appropriate and skilled management of adult cardiovascular problems. This requires an active caseload of diseases of the heart and great vessels and continued interest in the practice of adult cardiovascular surgery as evidenced by attendance and participation in appropriate specialty meetings and symposia. Involvement in research and education is necessary whenever possible.
Hospital Privileges
Cardiovascular surgery in adults includes surgical procedures as follows:
- Operations involving myocardial revascularization with both arterial and venous conduits.
- Operations involving repair or replacement of cardiac valves.
- Operations involving resection of cardiac tumors.
- Operations for obstructive cardiomyopathy.
- Operations involving thoracic aneurysms including atherosclerotic aneurysms and intrathoracic dissection of the great vessels.
- Operations involving stenosis or obstruction of the aorta and great vessels.
- Operations of the pericardium including resection, reconstruction, and drainage.
- Operations for congenital abnormalities of the heart.
- Operations involving repeat sternotomy or repeat thoracotomy after previous cardiac operations.
- Operations involving epicardial pacemaker lead placement and management of pacemaker electrophysiology in this circumstance.
- Critical care management and procedures including placement of central venous lines, Swan-Ganz catheters, arterial lines, and pacemaker leads; ventilator management; and total enteral and parenteral nutrition management.
- Operations involving the sequelae of wound complications subsequent to cardiac operations including sternal debridement, sternal rewiring, and hernia repair.
|
Congenital Heart Surgery
|
|---|
Congenital heart surgery encompasses the factual knowledge, technical skill, and judgment required to diagnose accurately and to manage surgically congenital heart defects in neonates, infants, and children. The nature and locality of this practice is often in children's hospitals and children's pavilions. Therefore, thoracic surgeons who emphasize congenital heart surgery also may be called upon to diagnose and treat childhood diseases of the thorax and vascular system that include, but are not limited to, diseases of the chest wall, pleura, lungs, trachea and bronchi, mediastinum, diaphragm, esophagus, or detailed above under the heading of General Thoracic Surgery. Congenital heart surgery requires an in-depth knowledge of the pathophysiology of congenital heart disease, diagnostic imaging, physiologic evaluation of organ function, preoperative evaluation, postoperative care, critical care, trauma, basic surgical oncology, and transplantation.
Education and Training
Thoracic surgeons who specialize in congenital heart surgery will usually have served a period of at least 6 months of focused training in congenital heart surgery in addition to the education achieved during thoracic surgical residency.
Clinical Competence
Competency in congenital heart surgery entails the continued appropriate and skilled management of congenital heart surgical problems. This requires an active case load of congenital heart diseases and demonstrated continued interest in the practice of congenital heart surgery, as evidenced by attendance and participation in appropriate specialty meetings and symposia. Involvement in research and education is desired wherever possible.
Congenital heart surgeons are specially qualified to manage complications encountered by medical colleagues who conduct cardiac catheterization and endoscopic procedures. The congenital heart surgeon is also qualified to assist in and to perform percutaneous transvascular approaches for the treatment of congenital heart disease.
Hospital Privileges
In addition to the procedures specified under the headings of general thoracic surgery and cardiovascular surgery in adults, congenital heart surgery includes the following services for neonates, infants, and children:
- Operations involving the repair and palliation of congenital and acquired heart defects using open (cardiopulmonary bypass) and closed techniques, optimal myocardial protection methods, and appropriate use of systemic hypothermia.
- Critical care management and procedures include placement of central venous lines, Swan-Ganz catheters, arterial lines, and pacemaker leads; ventilatory management (including use of inhaled nitric oxide); and total enteral and parenteral management.
- Cardiovascular support for infants and children including the prolonged use of extracorporeal membrane oxygenators.
Conclusion
The above definitions of the components of thoracic surgery are not to be construed as definitions of separate specialties. The definitions clarify areas of special interest and focused expertise within the specialty of thoracic surgery.
|
Long-Range Strategic Plan
|
|---|
I. Education
GOAL 1.
The Society should continue to create opportunities for the membership to participate in continuing medical education programs.
- Strategic Direction
The Society should continue its role in leading the specialty in new and continuing medical education opportunities.Action Plans- Develop new technology to help serve the needs of the members.
- Make the application of multimedia computer technology one of the highest priorities in continuing medical education.
GOAL 2.
The Society should be active in educational programs that reach other health professionals. This includes guidance in adapting practice to the exigencies of managed care.
- Strategic Direction
The Society should develop specific programs for targeted audiences.Action Plans- Develop specific initiatives to improve communications with primary-care practitioners and other specialty practices that are allied to thoracic surgery.
- Use multimedia computer technology as a tool for communication.
- Strategic Direction
In a period when limitation of resources is driving cost-control strategies and the search for more cost-effective medical care, The Society should have a major role in helping members answer the following question: Is managed care an acceptable system for allocating care? Included in this calculation should be a discussion of the ethical basis for managed care.Action Plans- Participate in the policy debate over who controls ("owns") the medical care of the patient and provide members with guidance in responding to local situations.
- Help define when the physician has a moral, professional, and legal obligation to say "no" to managed care and how to say it.
GOAL 3.
The Society should become more actively involved in determining the educational experiences provided through residency programs.
- Strategic Direction
The Society should help establish quality of the educational experience as the variable by which residency programs are judged.Action Plans- Use the statements regarding the end-product required for the practice of thoracic surgery that evolves from this strategic planning process as the basis for this involvement.
- Take a proactive position regarding what a new thoracic surgeon should be able to do on entering practice.
- Continue to support efforts to resolve problems with certification.
- Actively support a more effective application of standards by which training/educational residency programs are evaluated.
- Continue to encourage communications among The Society of Thoracic Surgeons, American Board of Thoracic Surgeons, Thoracic Surgery Directors Association, Residency Review Committee, American College of Surgeons, The American Association for Thoracic Surgery, Southern Thoracic Surgical Association, Western Thoracic Surgical Association, and American Board of Surgery.
GOAL 4.
The Society should encourage members to become more involved at the undergraduate and medical school levels of education with identifying and helping to define the future of cardiothoracic surgical practitioners.
- Strategic Direction
The Society should encourage members to do so by supporting individuals in undergraduate school and medical school through research opportunities and mentoring activities.Action Plans- Coordinate the STS program with the programs already in place in other specialties, such as the American College of Surgeons.
- Encourage development of educational opportunities afforded by the technology of the Internet.
- Develop a mechanism for involving cardiothoracic surgeons, particularly semiretired STS members, in the teaching of thoracic anatomy at the medical school and undergraduate levels.
- Develop mechanisms for financial support for undergraduate research projects that emphasize thoracic surgery.
II. Database Technology/Outcomes
GOAL 1.
The Society should recognize the changing role of computers in medicine and the impact of this change in information technology on all specialty medical care and on cardiothoracic surgery in particular.
- Strategic Direction
The Society should help practicing thoracic surgeons to understand and, where appropriate, use continuing changes in technology to affect methods of practice, productivity, and types and volumes of procedures.
- Strategic Direction
The Society should have a role in monitoring changes in technology and how they are disseminated throughout the practicing community.Action Plans- Promote further analysis of the impact of research on technology development.
- Assist in the development of algorithms for clinical application in:
- Clinical outcomes;
- Cost outcomes;
- Replacing less cost-effective care with most cost-effective care.
- Assist in establishing principles for the use of new technologies, including a review of their impact on:
- Surgical care at the beginning and end of life;
- New approaches to old problems;
- Possibilities for true cures rather than palliation.
GOAL 2.
The Society should continue to incorporate advancing information management technology into mainline cardiothoracic surgical practice.
- Strategic Direction
The Society should take appropriate steps to ensure that the software is optimally user friendly. Data input should be simplified and automated with origination from a single source.Action Plans- Develop methods for single-source automatic entry into the database.
- Improve software reporting flexibility.
- Keep open architecture so users can merge or join it.
- Provide aggregated (STS) data to users.
- Allow for subsets to be called into run and sort.
- Develop focus groups to determine how the database can become more user friendly.
- Develop easy graphics and ability to graph outcomes longitudinally.
- Increase the timeliness of data accessibility.
- Create ability for modem entry and develop technology for direct computer entry.
- Strategic Direction
The Society should make database information available for clinical decision support, at the bedside of individual patients.Action Plans- Educate surgeons on the strengths and weaknesses of data systems for use on an individual patient basis.
- Provide or encourage the use of hand-held calculators for the determination of expected mortality, morbidity, and other outcomes for individual patients.
- Broaden and improve risk stratification and increase its accuracy as determined by regional outcome experience.
- Include long-term data as a further aspect in clinical decision making.
- Strategic Direction
The Society should develop educational programs for multiple health care providers to facilitate use of the database for outcomes information.Action Plans- Educate STS members through a variety of programs, including Postgraduate Courses at the Annual Meeting and the development of self-help computer software programs, about the power of informatics.
- Educate data managers (organize and conduct meetings for data managers) to standardize data-collection methodology.
- Educate allied health profession assistants who make entries into the database (includes meetings for nurse managers and others).
- Educate Health Care Finance Administration, other public agencies, and third-party carriers through meetings with representatives of interested agencies.
- Educate the public as to what expected cardiothoracic services should accomplish.
GOAL 3.
The Society should improve the scope and reliability of the database information.
- Strategic Direction
The Society must develop additional validation methods for the database.Action Plans- Develop standards for definitions to be uniformly used in databases.
- Provide guidelines (monitoring) and auditing procedures that enhance the reliability of the database for the individual members.
- Develop consistency and audit checks.
- Monitor for inappropriate altering of risk-stratified data.
- Standardize data-collection methods for database participants.
- Assess completeness of the data elements (Database Committee).
- Perform internal and external comparisons (Database Committee).
- Strategic Direction
The Society should expand the current cardiac database to include the full range of procedures done in thoracic surgery with special emphasis on the services rendered by component specialties that have received little previous attention.Action Plans- Continue and improve the risk stratification for coronary artery bypass grafting.
- Develop risk stratification for the combination of coronary artery bypass grafting and valve replacement.
- Develop risk stratification for valve surgery.
- Develop risk stratification for pulmonary resection.
- Develop risk stratification for esophageal resection.
- Develop risk stratification for surgical treatment of congenital heart lesions.
- Develop risk stratification for lung volume reduction surgery.
- Develop risk stratification for lung and heart replacement, including devices and transplants.
- Develop standardized data collection on the following:
- Valve repairs;
- Congenital heart procedures;
- Bronchogenic carcinoma procedures;
- Esophageal carcinoma procedures;
- Electrophysiologic procedures;
- Thoracic and peripheral vascular procedures;
- Heart, lung, and heart-lung transplantations;
- Ventricular assist device procedures;
- Lung volume reduction procedures;
- Resource utilization such as:
- Length of stay;
- Return to intensive care unit;
- Diagnostic studies;
- Patient satisfaction;
- Quality of life;
- Practice costs.
- Develop standards for data collection for patients who have been seen but not operated on.
GOAL 4.
The Society shall determine and regulate the confidentiality as well as the dissemination of the data.
- Strategic Direction
To assure continuing acquisition of valid data, the primary concern of The Society is the maintenance of confidentiality of the information in all categories.Action Plans- Determine methodology to maintain confidentiality of individual data while simultaneously allowing for dissemination of material identified by the database oversight committee. This will be reviewed by legal counsel.
- Establish guidelines for release of the information.
- Define who gets data:
- Surgeons;
- STS members;
- Third-party payers;
- Health maintenance organizations;
- Hospitals;
- State and national government agencies;
- Consumers/users/patients.
- Determine when and which identifiers should be used:
- Patient specific;
- Surgeon specific;
- Group specific;
- Hospital specific;
- Geography specific;
- Payers by insurance type;
- Combinations of these.
- Determine who has access to existing national data at present.
- Obtain information from other databases on data-release policies.
- Determine which elements of information go to each of the user groups.
- Determine if nonmembers should be able to analyze the data and, if so, under what conditions.
GOAL 5.
The Society shall develop material defining the value of certification by the ABTS to show that ABTS certified surgeons provide higher quality and more cost-effective patient care than other noncertified providers.
- Strategic Direction
The Society should educate patients, third-party payers, and providers about the services, including outcome data provided by thoracic surgeons.Action Plan- Develop material that defines the unique value of thoracic surgical services.
- Strategic Direction
The Society should promote and emphasize the following services that are provided by thoracic surgeons and other surgeons: operations that do not require cardiopulmonary bypass or cardiopulmonary bypass standby but that involve the lungs, mediastinum, esophagus, chest wall, great vessels, thoracic inlet, and diaphragm.Action Plan- Develop material that defines the value of the following risk-stratified thoracic surgical services:
- General thoracic surgery- lung resection to treat cancer;
- Coronary artery bypass versus interventional cardiology;
- Treatment of patent ductus arteriosus in neonates;
- Treatment of esophageal dysfunction.
III. Workforce/Workplace
GOAL 1.
The Society should determine whether positions are and will continue to be available in thoracic surgery for those who invest 2 to 3 years in formal thoracic surgical education beyond general surgical training. The Society should also be actively involved in resolving the basic issue of how to match residency and fellowship training positions to available positions and available cases in the market.
- Strategic Direction
The Society should determine whether the number of providers of thoracic surgery is now and will continue to be appropriate and whether the numbers and their appropriateness can be projected into the future.Action Plans- Identify the numbers of cardiovascular and thoracic surgeons currently practicing.
- Identify current nationwide case volumes. To accomplish this, determine what information is available from the National Hospital Discharge Survey and from states that now collect hospital discharge data.
- Insofar as one can do so, determine which other specialists are doing thoracic surgical procedures. Determine where, how many, and with what frequency the cases are being done by ABTS certified surgeons versus surgeons not certified by ABTS.
- Initiate a continuing mechanism, such as an annual or biannual assessment of the STS workforce surveys, to evaluate workforce needs, including consideration of:
- The aging of the thoracic surgical workforce and other factors affecting their expected exit from clinical activity;
- The productivity of thoracic surgeons by subspecialty;
- Any sex-related issues at resident and staff levels affecting the workforce and workplace.
- Strategic Direction
Determine whether and how the thoracic surgical workforce needs of the future can be projected.
GOAL 2.
The Society should be actively involved in reviewing and defining the issues of professional productivity in thoracic surgery on which workforce or workplace decisions will be made.
- Strategic Direction
The Society should review the issue of productivity and develop appropriate position statements, including a definition of productivity and how to measure it.Action Plans- Determine whether there should be a minimum surgical volume for certification. What number of cases is necessary to be competent on the basis of training, experience, and age?
- Be proactive in determining whether there should be subcertification for various aspects of thoracic surgical subspecialties (pediatric, transplantation, video-assisted thoracic, peripheral vascular, arrhythmia surgery, and oncology). Alternatively, is there too much subspecialization?
- Develop a position on economic credentialing.
- Consider the role of the thoracic surgeon regarding additional responsibilities at various stages in his or her practice, and the resultant changes in workload and surgical productivity. Elements such as research, clinical and academic experience, and service to the specialty should be a part of the equation.
- Study how to assist in developing future leaders of the profession, including how refocusing or retraining should proceed during the course of a lifetime in medicine.
- Strategic Direction
The Society should actively gather data necessary to assess the reconfiguration of practice patterns that is now occurring and the potential impact on the workforce.Action Plans- Review changing practice patterns and how they may affect future workforce needs, including:
- The role of trained thoracic surgeons and other providers at various levels of care in surgery;
- Gathering demographic, clinical, and financial data as the basis for establishing case mixes;
- Specialty specific information on managed-care contracts with global fees or capitation as the basis for relations between patients, payers, and providers;
- Identifying criteria for stratification and distribution of cases based on risk as the basis for regionalization and network strategies;
- The development of single-specialty groups with multiple areas of expertise or of multispecialty groups;
- Encouraging cooperation between private and academic practices.
- If the number of cardiovascular and thoracic surgeons to be trained is to be reduced, consider how to accomplish this. Various measures include:
- By quality of programs;
- By case volume;
- By proportionality among all programs;
- By ability to place graduates after training;
- By sex, ethnicity, geography, or other criteria;
- By lottery.
GOAL 3.
The Society should consider strategies for encouraging state or regional chapters to form as a prelude to developing appropriate future clinical or academic regionalization strategies.
- Strategic Direction
Recognizing that there are differing regional markets for thoracic surgeons, The Society should consider the impact on the thoracic surgical workforce of regional variations, including differing roles of nonphysician assistants and care givers (nurse practitioners and physician assistants), primary care physicians, pulmonologists and cardiologists, general surgeons, and certified cardiothoracic surgeons.Action Plans- Assist in developing regional data from nonboarded cardiovascular or thoracic surgical sources and monitor outcome data by source of treatment provider.
- Recognize case stratification as a rational driving force for referral within regions and consider whether there should be steerage by physicians or other criteria of cases within regions to meet the conditions defined by case-mix guidelines.
- Assist cardiothoracic surgeons from differing regions to focus on the commonality of problems in their areas.
IV. Cost-Containment/Reduction
GOAL 1.
The Society should be directly involved in educating its members about cost containment and the cost-containment/reduction process.
- Strategic Direction
The Society should distribute information on cost containment/reduction.Action Plans- Establish an Internet address.
- Establish a "Best Practice" segment in Internet and The Society Newsletter.
- Make cost containment the main focus of the Postgraduate Course.
- Solicit papers on cost containment/reduction for presentation at the Annual Meeting.
- Create a symposium with a strong faculty on cost containment/reduction.
- Upgrade The Society Newsletter by soliciting funds from industry.
- Strategic Direction
The Society should strongly encourage its members to be actively involved in the cost-containment/reduction process in their practices.Action Plans- Encourage full participation in the database/data collection for the purpose of outcome evaluations.
- Develop an extensive list of cost-reduction techniques (for direct and indirect costs) that can be adapted to a wide variety of practice types.
- Develop ways for integrated services to be used and ways to eliminate the "middle man"/broker when working with managed-care organizations.
- Provide assessments of various cost-based accounting systems for use by the membership.
- Develop support through studies and research on the use of physician extenders such as the physician assistant and the nurse clinician.
- Disseminate the Practice Expense Study analysis to the STS membership as soon as possible.
- Strategic Direction
The Society should work with other organizations to promote effective cost containment/reduction.Action Plans- Develop the concept that the cost of medical education is a societal responsibility and not just that of the physician. This cost should be factored into reimbursement issues. Work with the American Medical Association and the American College of Surgeons to implement strategies to this end.
- Determine if organizations such as the American Heart Association, American College of Cardiology, and American College of Chest Physicians are willing to work with The Society to find ways to reduce costs. Establish mechanisms to implement these working relations.
- Strategic Direction
The Society should prepare a policy statement that emphasizes that any cost savings should be used to support the provision of clinical services to patients in need.
GOAL 2.
The need of cost containment requires that thoracic surgery be practiced in an integrated, multidisciplinary fashion by chest-disease specialists. The work done by these specialists must be defined in terms that are readily understood by specific audiences such as patients and third-party payers.
- Strategic Direction
The Society shall inform patients and other specific audiences about the services offered by thoracic surgeons in terms that are easily understood.Action Plans- Develop educational materials for the following audiences:
- Patients and their families;
- Referral sources (including but not limited to)
- Generalists
- Primary care physicians and specialists not listed;
- Specialists
- Cardiologists for adults;
- Cardiologists for infants and children;
- Respiratory medicine/critical care physicians;
- Medical oncologists;
- Gastroenterologists;
- Healthcare payers
- Government agencies;
- Private insurance companies;
- Other corporate units such as managed-care organizations.
- Strategic Direction
The Society shall, with professional assistance, develop specific audience presentations about thoracic surgery.Action Plans- Appoint a committee for information dissemination.
- Support professional assistance for information dissemination.
- Develop specific training courses for the STS membership to learn how to present the facts relating to their specific practices to specific audiences, eg, patients and insurance companies.
GOAL 3.
The Society shall develop material supporting the value of thoracic surgeons who provide high-quality, cost-effective patient care.
- Strategic Direction
The Society should educate patients, third-party payers, and providers about the services, including outcome data, provided by thoracic surgeons.Action Plan- Develop material that defines the value of unique thoracic surgical services.
- Strategic Direction
The Society should promote and emphasize the services provided by thoracic surgeons. Thoracic surgeons perform the following operations that do not require cardiopulmonary bypass or cardiopulmonary bypass standby but that involve the lungs, mediastinum, esophagus, chest wall, great vessels, thoracic inlet, and diaphragm. Note that this list is not exhaustive.Action Plan- Develop material that defines the value of the following risk-stratified thoracic surgical services:
- General thoracic surgery-lung resection to treat cancer;
- Coronary artery bypass versus interventional cardiology;
- Treatment of patent ductus arteriosus in neonates;
- Treatment of esophageal dysfunction.
GOAL 4.
The Society recognizes the membership needs of disease management strategies. Therefore, The Society should develop an effective educational process to meet the membership needs of disease management strategies.
- Strategic Direction
Guidelines that avoid a "top-down" flow of information are necessary.Action Plans- Develop templates that allow for local needs and diversity in guidelines.
- Develop a multiinstitutional study on the effectiveness of guidelines through funding by industry.
- Establish a monitoring system that the STS membership can use to report the effectiveness of the guidelines.
- Develop a policy statement that promotes universal accessibility of the guidelines, which are not proprietary.
GOAL 5.
The Society should form alliances with related medical-specialty organizations to develop cost-containment/reduction strategies.
- Strategic Direction
The Society shall participate in or form coalitions of like-minded specialties to develop cost-reduction information and strategies for physicians.Action Plans- Appoint and support allied specialty committees charged with cost-containment missions.
- Provide professional assistance by preparing materials for patients, legislators, and third-party payers that demonstrate the value of specialized thoracic surgical care and promote the premise that all cost reduction must be passed on to the public.
|
Footnotes
|
|---|
Address reprint requests to Headquarters, The Society of Thoracic Surgeons, 401 N Michigan Ave, Chicago, IL 60611-4267.
|
Reference
|
|---|
- Wilcox BR, Waldhausen JA. Report of the Joint Conference on Graduate Education in Thoracic Surgery. Executive summary. Ann Thorac Surg 1993;55:1349–56.
This article has been cited by other articles:
|
|
|
|
 
J. R. Benfield
Surgical education in changing times
Eur J Cardiothorac Surg,
September 1, 1999;
16(Supplement_1):
S6 - S10.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. B. Orringer
What Shall We Call Ourselves? The Time for Standardization
Ann. Thorac. Surg.,
September 1, 1997;
64(3):
596 - 598.
[Full Text]
|
|
|
Top
Foreword
Strategic Directions Committees