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Ann Thorac Surg 1997;63:923-929
© 1997 The Society of Thoracic Surgeons
Ingalls Memorial Hospital, Harvey, Illinois
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Introduction |
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 TopFootnotes Introduction References |
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The Presidential Addresses of this Society, however, have been distinguished by their erudition, scholarliness, and wit, and characteristically have focused on historical, educational, or socioeconomic issues. I am handicapped by the fact that I am not a scholar. I have been influenced by the comedian Mort Sahl, who borrowed from Will Rogers the technique of commenting on the humor of the daily life exhibited by the media. I shall attempt to convey to you my amazement of the absurdities of our modern society by illustrative vignettes garnered from the press, and then to suggest how the new technology of electronic media might enable sincere, motivated cardiothoracic surgeons to put things right.
Doctor Denton Cooley gave his Presidential Address two years ago on "Fifty Years in Cardiac Surgery." The events of which he spoke that transpired over the past 50 years are ones of high achievement, born of imagination and creativity, and were applied universally, bringing relief to millions of people afflicted with diseases of the chest. Surgeons involved in that heady rush to excellence were treated like heroes, not altogether dissimilar to the astronauts of the early space exploration days. Not only was the work challenging and interesting, not only did patients and the public kiss our hands, we also were paid well. What could be better?
Like all wonderful things, this period of high excitement and endless rewards passed. We should have been more thoughtful, but in my opinion we were anesthetized by the unrealistic expectations produced by the economic and social boom of the 1950s. While the rest of the world was digging out from the ravages of World War II, the United States was in a mood of invincibility and ever-expanding achievement. I know because I was there. Eisenhower was President, and he provided a calm, measured approach to the process of government. The charisma of John F. Kennedy, coupled with the optimism of a prosperous country, gave rise to a host of social programs, promulgated by Lyndon Johnson, that brought great good to many people, brought the largest transfer of wealth in history, and has nearly bankrupted a nation. Whether you believe, as I do, that it also condemned a large portion of a generation to a lifetime of dependency is irrelevant, because whatever the future, in this case the past is not prologue to its future. The simple fact is we do not have enough money to continue the entitlements for our citizens beyond those truly necessary. I believe that there is enough money to take care of those in real need; however, we do need to identify who they are more realistically.
The well-intentioned efforts to cure social problems have had many unexpected, sometimes humorous, often tragic consequences. Rather than alleviating all our social problems, they have exacerbated some. Teenage suicides are rising at an alarming rate, the number of unwed mothers has reached epidemic proportions, SAT scores are falling like a stone (despite the efforts of the College Board to lower the scoring standard), faith in government has reached an all-time low, and you cannot pick up a newspaper without becoming depressed with the increases in crime. Medicare is broke, physicians are mistrusted, managed care organizations are applying "bottom line" directives to patient care, and Kervorkian is cheered as he administers pentothal, pancuronium, and potassium. Every parent knows, or should know, that providing children with everything they want without instilling in them the notion of personal responsibility and individual accountability is a ticket to failure.
Now, I will have to establish a few ground rules for this talk. I cannot sort out all the ills of society in 45 minutes, so I will restrict myself to medicine in general, and thoracic surgery in particular. Give me another 30 minutes and I might address other societal concerns, but the potential solutions there will be painful, and I do not perceive many citizens remaining in this country once renowned for its pioneering spirit ready for pain.
How did we get into this mess in health care? It seems to me simple to explain: we gave everybody everything they wanted. Read Joseph A. Califano, Jr, in Radical Surgery [1], "To pry Medicare and Medicaid out of the Senate Finance Committee, Johnson had to agree to pay hospitals their costs plus a guaranteed percentage, and to pay to doctors fees that were `reasonable,' `customary' and `prevailing' in their communities-a reimbursement scheme commercial insurers had rejected for years because it gave physicians the power to raise their own fees.
When told by Wilbur Cohen, Secretary of Health, Education and Welfare that "it'll cost a half-billion dollars to get the bill out of the Senate Finance Committee," Johnson responded "Five hundred million, is that all?" "Do it. Move that damn bill out now before we lose it."
Califano continues, "I was on the White House staff as Johnson's top domestic aide. We feared that with too few doctors to handle the increased demand from new federal programs, the price of their scarce services would rise. Over the strenuous objections of the American Medical Association, we rammed through legislation to provide funds to double the number of doctors graduating from medical school each year from eight thousand to sixteen thousand-We have since discovered that more doctors mean more care and higher health care costs" (emphasis added). Although the innocence of his original reasoning is charming, the mindlessness is breathtaking. Imagine my astonishment when, as I watched the Clinton Healthcare Plan evolve, who should be on the media panels as an expert discussing what should be done for the healthcare problems of our country-you got it, Joseph Califano, Jr.
It has taken nearly 30 years before the final realization of the enormity of the financial impact of these social programs has been generally recognized. The secret was kept from the public, cleverly, by the simple expedient of borrowing from ourselves and everyone else in the world until we finally got a phone call from the great Visa monitor in the sky that we were overdrawn. In casting about for villains to blame, physicians were a prime target. We had participated in a huge cost overrun, because we did just as we were told to do. We provided the best possible medical care in the world for as many people as we could, and we were paid usual, customary, and reasonable fees, as we determined them to be, also as we were told to do.
During the early warning phase of this shambles, in typical government fashion, it was determined that the solution for the high cost was to create a regulatory bureaucracy. Thus it came about that there was an increase in Health Care Administrators from 1968 to 1995 of 692% while the number of physicians increased by 77%. By 1993 27% of the total healthcare employment was healthcare administrators, while the total for physicians and nurses was 43%. If you consider that for every 1.5 physicians and nurses, there is 1 administrator, it gets even more impressive [2]. The effect was to drive up costs even higher. Much was made of the fact that the United States health care costs ran about 2% to 3% higher than those in Canada, but it was rarely mentioned that most of this difference could be explained by the higher administrative costs in the United States.
We have been inundated by misrepresentations, erroneous statistics, and bald-faced lies. Some of these are so pathetic that they would be comical if they were not taken seriously by health policy gurus. Let me give you a wonderful example from the International Journal of Health Service [3]. The abstract reads as follows:
The relationship between the availability of primary care and speciality care and certain life chance indicators such as mortality rates and life expectancy is analyzed using the multiple regression procedure. Dependent variables are life chance indicators: independent variables were selected based on Starfield's and Blum's health determinant models and include socioeconomic environment, lifestyles, demographics and medical care. The author also examines the rankings of states in terms of these indicators, using Spearman's rho coefficient. Among the health care variables, primary care is by far the most significant variable related to better health status, correlating with lower overall mortality, lower death rates due to diseases of the heart and cancer, longer life expectancy, lower neonatal death rate, and lower low body weight. In contrast, the number of speciality physicians is positively and significantly related to total mortality, deaths due to heart diseases and cancer, shorter life expectancy, higher neonatal mortality and higher low birth weight. From a policy perspective, a likely implication is to reorient the medical profession from its current expensive, clinically based, treatment-focused practice to a more cost-effective, prevention oriented primary care system (emphasis added).
The disturbing aspect of this article is that the author is so uninformed about population bias and clinical controls that he arrives at this conclusion without even being aware of the fallacies of his argument. These conclusions are common in the health policy literature, giving rise to a conviction that medical problems will be resolved easily and inexpensively with simple primary care. A similar tortured logic arises from the observation that because the mortality rate for heart disease and cancer goes down when the American College of Surgeons has its annual Clinical Congress, the College should consider having bimonthly Congresses.
Now folks, this is what we have to contend with. Bear in mind that a lot of this is coming from the efforts of three large Foundations. The W. K. Kellogg Foundation states "the foundation's long-term goal is not to simply change the balance between generalist and specialist physicians. Rather it is to prepare more primary care professionals with the values, skills, and perspectives associated with promoting health and preventing illness and with community in its broadest sense." What does that mean? If you want to prepare someone with skills, does that mean provide them with residency training? What does "promoting health and preventing illness and with community in its broadest sense" mean? The Pew Charitable Trust lays out its mission "to define the primary care system and the roles and responsibilities of practitioners in it; redirect training to community-based outpatient settings (including managed care); determine financing changes needed to support the shift in training; help the public understand what to expect from primary care and how to use it more effectively; and at the same time, clarify the career options available to health professions students" (emphasis added). Finally, the Robert Wood Johnson Foundation has as its goals "first, training and leadership development, for example the Generalist Physician Faculty Scholar Program-another program, The Generalist Physician Initiative was begun to stimulate the `internal market' for generalist physicians. A fourth program concentrates on the development of primary care practice in communities" [4].
Now, few in this audience would take exception to the importance of primary care in a health system. However, there are increasing numbers of studies that support the position that if you have a serious health problem, you are better served consulting a specialist physician [5–7]. The Foundations' misguided emphasis does not directly affect cardiothoracic surgeons, because we are not competing with primary care physicians. However to destroy without scientific basis the foundations of the best healthcare system in the world in the hope that the laying on of hands by a kindly generalist doctor would cure cancer, heart disease, trauma, and mental disease would seem to be foolhardy to me. The mythology that much of the disease plaguing our country can be resolved by establishing preventive programs requiring little more than good motherly advice is leading to poor public policy.
Fortunately for the health of the United States, the public is not completely buying into this strategy. There is some merit to the notion of the wisdom of the public, although on occasion it is difficult to argue with the statement attributed to Carlisle, "I will not accept the notion of collective wisdom derived from individual ignorance." When asked, in a poll taken by the Louis Harris group, what the most important considerations were when choosing a health plan, 82% of the respondents said a very important consideration was "the ability to go to a specialist of their choice" [8]. In a poll conducted by the Kaiser Foundation [9] asking what various physician characteristics influenced their choice of a doctor, 71% of the pollees said that it was very important to them that the doctor was board certified or had additional special training. In contrast, only 30% answered that the reputation of the doctor's medical school or training program was very important, whereas 10% replied that race or ethnic background was very important (a comforting thought that racism may not be as prevalent as reported), and 25% responded that a high rating by a government agency was very important. The highest consideration was how well the doctor communicates and is caring; 84% listed that as a very important characteristic. Think about that for awhile.
The progress that has been made in cardiothoracic surgery in the past 25 years staggers the imagination. Despite the best efforts by governmental agencies, managed care accountants, plaintiffs' attorneys, and nonsurgical physician groups (including the American Medical Association) to impugn the quality and importance of our work, it is widely recognized that the value of cardiothoracic surgical services has risen, while the cost has gone down. The business community has been quick to point to the reductions in cost of computer memory, justifiably so, but the analogies between the computer chip and cardiothoracic surgery are closer than you might think. Russell [10] points out that the cost per year of life saved varies enormously with the type of medical intervention. The results of her analysis are considerably disparate with the health policy strategies currently in vogue. An example is shown in Table 1
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How is it that surgeons have raised the level of the value and quality of their service and no one has noticed? Judging from the responses that we witnessed from the media, insurers, government agencies, and even some consumer groups, you would have thought just the opposite had taken place. Why is this? I will tell you why. It is not that there is some conspiracy; it is because the cacophony of noise being raised by all manner of well meaning (for the most part) but uninformed sociologists, economists, and health policy wonks, encouraged by doctors with their own special agendas, drowned out the voices of surgeons who have been "too busy" to get informed and become involved. It was just so darn obvious to us that the importance of our work was crystal clear, that we just waited for everyone else to wake up. Well, folks, they have not, and if we do not succeed in waking them up the future for patients with chest disease in this country is grim.
Fortunately, we still have one big group, the most important group, in our camp: the people of this country. Let me give you some more polling numbers. Polls seem to be the way things are sorted out these days. When asked "Who is most responsible for overall quality of care in a health plan?", 53% of respondents replied the doctors, and 25% replied the health plan [9]. Asked whether it was wise to force doctors to follow managed care–mandated guidelines, 56% replied it was a bad thing; 39% said it was a good thing [9]. Polled about which sources of information were most believable about the quality of health care, 12% of respondents replied health plans were very believable, 29% said individual doctors were very believable, 50% believed their friends or family, and 34% trusted surveyed patients, whereas only 7% thought government agencies and 5% thought newspapers or media were very believable. Table 2 illustrates the point further.
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In reflecting on where we, as a profession and a speciality, are today, I would sum it up as follows. Despite a steady torrent of bad press, some deserved, most not, we still have considerable credibility with our patients, representing the critical public. We are certainly more credible than our most consistent tormentors-government, the media, and managed care organizations. We need to forget about getting favorable treatment from the media; the best we can hope for is honesty, which is all too infrequently apparent. Plastic surgeons have been dismayed by the portrayal of them by the media coverage of the breast implant debacle, but did not or could not map out a clear strategy for overcoming the bad press [12]. My notion is that if we can get favorable recognition from the media, good, but if we do not, we need to go around the press and establish connections directly with our patients.
Fortunately, we have the means to circumvent the press altogether. The new world of cyberspace, the Internet, and the World Wide Web will make it feasible to go directly to the public, establishing contact in a way that has never before been possible. The Society of Thoracic Surgeons has established a Web site that is a joy to behold, the result of enormous effort by a group of young, bright members who are leading the way in the new world of Informatics. Doctor Peter Greene and his associate Dan Jacobson have been intellectually brilliant and indefatigable in their efforts to provide our members and colleagues with the tools to participate in this electronic revolution. Not all these young, brilliant people are necessarily chronologically young. The youngest, most forward thinking of the group are the editor of The Annals of Thoracic Surgery, Dr Thomas Ferguson, and his administrative editor, Carol Blasberg. In my opinion, their achievement will make it possible for the STS to marshall the forces that might enable us to turn the relentless tide of media disinformation that has confounded and confused patients and physicians alike.
Earlier this year the STS Web site hosted a discussion of lung volume reduction surgery for those cardiothoracic surgeons who were involved and interested in the clinical studies that were being proposed. As the discussions proceeded, we were surprised to find patients and family members of patients suffering from chronic lung disease becoming involved in the discussions on this Web site. This electronic involvement has led to the development of a patient advocacy group, highly motivated and intelligent people, intense in their interest in chronic lung disease. These people will be a great asset to physicians who wish to do the right thing for their patients but who are hindered in their efforts by the inability to communicate directly with patient groups.
The STS Web site continues as the home for STS business. For the members of the STS, the STS Web page will be the primary source of connection to our Society. However, to provide a single Web site resource for the cardiothoracic surgical community all around the world, a generic CTSnet (Cardiothoracic Surgery Network), has been developed, which will serve to link together related cardiothoracic organizations, such as The American Association for Thoracic Surgery, international surgical societies, the American Board of Thoracic Surgery, the Thoracic Surgery Directors Association, and the Residency Review Committee for thoracic surgery. Using this technology, surgeons will be able to communicate with each other and with patients in every part of of the world as easily as we use the telephone today. Within the next few years, most of us will get a large part of our information from these electronic sources, substituting news that currently is edited by the media before we are able to see it for direct, straight from the source comment from informed citizens. It will be a real test of whether democracy really works, and a real test of the ability of the educational system of the United States to bring our young people into the electronic world.
The capability to communicate as easily and effectively with all our colleagues throughout the world as we do with our next-door neighbor means a total revolution in our thinking about competition in the global market for cost and quality. We have been informed regularly about the competition that exists for manufactured goods throughout the world. Until now we have not given much thought to the possibility that surgical services will also be competitive, not only within the United States, as they are increasingly so today, but within a global market for such services. Doctor Vincent Dor, Director of the Center for Cardiothoracic Surgery in Monaco, has published the cost to patients for cardiology and cardiac surgery services in his Center openly on the Internet. His initiative heralds the beginning of fair, open competition that will only be good for patients. If there is a logical solution to the cost of health care, it seems to me that it will come from honest competition, encouraging the creative skills of entrepreneurial doctors.
Because the limiting factor in simple cost reduction is to do so while continuing to maintain high quality, we sorely need appropriate methods to measure quality of performance. The STS is planning to join with other cardiothoracic organizations throughout the world to develop collaborative world-wide databases for outcomes analysis. The Internet will be most useful in this venture as well, because it will make it possible for us to construct and use databases in the most efficient way, and eventually to permit patients to do their own investigation into the performance of their surgeon.
The educational opportunities that will be derived from the Internet are inspiring. Residents are organizing their own educational pages on the STS Web site, surgeons are discussing puzzling cases, and The Annals of Thoracic Surgery is on the Internet in full text for all to use. Textbooks of thoracic surgery will be electronically published; one will be able to do literature searches from the ski lodge (if desired) on the Internet using Medline.
If we now have the means for effective communication, what do we want to communicate and how do we know that we can get a message to our patients that will be believed? We need to reestablish our professional credibility in such a meaningful way that those voices that speak out against us will not overcome us. To initiate the changes that will reestablish our professional credibility we need to do the following: (1) develop examples of and publicize the value of our services; (2) maintain high standards of education and training; (3) define, measure, and report quality of performance; (4) reestablish collegiality; and (5) maintain the highest standards of ethical behavior. Although most cardiothoracic surgeons already are following these tenets, there are a few disturbing signs that all is not perfect in our speciality. Although it is not as disturbing as it is reported to be, nevertheless it is worrisome.
I marvel at the extent of the power and control that we have over the professional aspects of our work that has been given to us freely, even enthusiastically, by the public. We are permitted to set the standards and requirements for (1) admission to the profession, (2) defining professional activities and scope of practice, (3) licensure, (4) certification of special skills, and (4) the ethics of practice. No court in this country would consider finding a physician guilty of unethical or negligent practice without testimony from another physician; no hospital would permit a physician to practice without a review and approval by a physician committee; no medical school would give a diploma to any student who was not approved by the physician faculty; and no specialist could complete special training or be examined for certification unless the training or examination were approved by specialist physicians.
If we are unhappy, why are we so? Is it because payment for our services is poor, is the work unsatisfying, do we regard our colleagues as unworthy, do we mourn the lack of public approval, do we resent the intrusion of forces from outside our profession changing our practice patterns-is it all of these? If we are unhappy with the changes in our profession, how do we make it right?
I believe that we need to examine carefully what patients want and expect from us. Patients are our strength, our support system, our foundation. Patients know far better than the Health Care Financing Administration's economists the value that we give to their lives. The intimacy that comes from one human putting his or her hands in another human's chest to take out a tumor or replace a defective heart valve transcends nearly any other level of interpersonal involvement. Patients know that we are there for them at any time of the day or night. No matter how terrible the problem, the surgeons will respond, will do their best, and will stay until the end. We need to shout this out at every occasion, to anyone who will listen, or anyone who will not listen.
We are at the threshold of the most amazing technological leap since the invention of the radio or the use of electricity. I am so happy that I had the chance to witness the development of cardiac surgery. My teacher, Dr Robert E. Gross, was there at the beginning. And now I can say to you that the impact of the new telecommunication technology will have an impact on human life greater than cardiac surgery. Those of you who do not understand how lucky you are at being here while this revolutionary new technology is being developed should think again of your good fortune. Because of it we are going to be able to have ready and convenient access to information in a way never before thought possible.
Vast amounts of information will become available. We will need to be able to interpret it; we will need to take the time to understand not only what we do, but what economists, health policy makers, politicians, and consumer advocates do and think. We will need to establish coalitions with groups interested in keeping this great health care system of ours intact, and the means to do this is right at hand. Some of these groups may seem at first glance to be unlikely candidates for making coalitions with us, but they are all patients, or will be. Patient groups, organized labor, other specialist physicians, insurance companies, industry, academic institutions, hospital associations, and even some government agencies are all possible allies.
Our speciality has not really thought much, if at all, about establishing coalitions. If we did think about it, sort of in passing, we did not go the extra mile to carry it out. Part of the problem is we spend so much time in the operating room, we are busy doing all kinds of things, and academic advancement or even professional recognition does not come from making a stirring speech to the American Association of Retired Persons. The other problem is that our speciality has a disjointed mode of leadership. We elect a president every year, we have two or three council meetings a year, and we have a few more conference calls of the executive committee than that, but we need more cohesive organization. And we are better than most; as a matter of fact, many other organizations are dazzled by the accomplishments of the STS when they find out that we have only 3,200 members. We are able to do what we do because we are more energetic, and certainly smarter than the rest. We can establish coalitions. The time is right because so many are sitting out there in distress, anxious about what they justifiably recognize as a formula for disaster being concocted by a blizzard of sociologists and economists posing as health care policy experts. I think most ordinary people, when put to the test, realize that we cannot regulate our way out of this dilemma. Sure, when the question is put to them, they will say all we have to do is is cut out fraud, waste, and abuse and cut doctors' and hospitals' fees and everything will be alright. They think that because politicians and media sources tell them that all the time, day in and day out. But when you sit down with patients and spend a little time with them to explain the real facts of the current situation, they get it. We must consider ourselves as teachers, not just of residents or allied health people, or even teachers of good health habits. We need to teach patients about the methods of delivering health care, about the political forces that are intruding between them and us, and about the type of health care that we think will be most valuable. We have direct daily personal access to our friends, the patients. Those who we cannot reach personally we can reach electronically. If we do that every day, the threats that seem so critical today will soon disappear.
The problems that face our speciality today pale in light of the hurdles that faced Gross, Gibbon, Blalock, Crafoord, and all the others as they pioneered this field. There is no doubt in my mind that we can overcome the problems that face us, but we, all of us, not just a few of us, need to step up, get involved, and work every day to put things right. If those of you who read this, or listen to it, do not realize that, you deserve what you are going to get. If we lose what we have inherited from our predecessors, we will never get it back.
It has been a wonderful year. I wish all of you could have the same opportunity, and some of you will. Thanks for the privilege.
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Footnotes |
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