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Ann Thorac Surg 1999;67:897-902
© 1999 The Society of Thoracic Surgeons
a The Virginia Mason Medical Center, Seattle, Washington, USA
Address correspondence to Dr Anderson, Office of Value Assessment, The Virginia Mason Medical Center, 1100 Ninth Ave, P.O. Box 900, Seattle, WA 98111
e-mail: ctsrpa{at}msn.com
Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.
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I am deeply grateful for the honor you have given me by electing me President of The Society of Thoracic Surgeons. I am also grateful for the opportunity to work closely with so many of you during the past year on the tasks in which the Society is engaged. Serving as your President has shown me how important it is for thoracic surgeons to work together to meet the challenges of an increasingly complex health care environment.
Thoracic surgery is a discipline invented and grown to maturity in this century. Its development mirrors the unprecedented advance of scientific knowledge that is the hallmark of our times. However, our profession has been shaped increasingly by profound social and political changes in our culture. My purpose in this address is to describe how the twin influences of scientific innovation and societal change have interacted to produce thoracic surgery at the century’s end.
Surgeons entered the 20th century with only a few of the tools that would permit them to operate on the chest. Through the 1920s, thoracic surgical operations were performed mainly on the chest wall. During the 1930s, operations within the chest became feasible when positive pressure ventilation and endotracheal intubation solved the open pneumothorax problem. The introduction of techniques for pulmonary and esophageal resection at last made lung and esophageal cancers treatable. Cardiac surgery in the early part of the century was limited mainly to occasional success in the suture of cardiac lacerations. Early closed operations on the cardiac valves were attempted beginning in the 1930s, but success was elusive and infrequent.
Consistent success was needed to excite general interest in the surgery of the heart and to demonstrate to the skeptics that surgery had a place in the treatment of heart disease. This was finally achieved with successful ligation of the patent ductus arteriosis, repair of coarctation of the aorta, and relief of pulmonic stenosis. The surgeons who developed these operations were not only brilliant investigators and technicians but were also inspiring teachers who motivated a whole generation of thoracic surgeons to work in the treatment of heart disease. Support for the laboratory research that led to these pioneering operations was, with few exceptions, drawn from endowments, local charities, and often from the practice income of the investigators themselves because there was little public support for medical research.
Military surgery during World War II introduced the early treatment of hemothorax and the successful removal of foreign bodies from the heart and great vessels. However, the most important advances were in supportive measures, including the development of blood banks, the creation of specialized units to treat thoracic injuries, better preoperative and postoperative care, and the use of the early antibiotic drugs.
During the war years science produced remarkable achievements, from radar and the atomic bomb to large-scale production of penicillin. After the war there was a growing sense that many of society’s problems could be solved by the right combination of money and science. In 1948 Congress created the National Institutes of Health with the authority to make grants to medical scientists. Its budget grew from $46 million in 1950 to $400 million in 1960 [1]. Thus were seeds sown that would result in the tremendous growth of medical science and technology in the second half of the century. This opening of the public purse for medical research also marked the first step of the government’s march into medicine.
Cardiac surgery was born in the 1950s. Although successful closed operations on the cardiac valves had become more frequent, major advances were made in the treatment of congenital heart disease. Suspension of circulation by using hypothermia and inflow occlusion provided just enough time for closure of atrial septal defects under direct vision. Repair of more complex defects within the heart required more time. This was first achieved through cross circulation using a human donor as both pump and oxygenator. Closure of ventricular septal defects and total correction of tetralogy of Fallot were performed using this technique. Meanwhile, the mechanical heart-lung machine, which had been under development for nearly two decades, was successfully used, and by the mid-1950s several types were in use. Extracorporeal circulation using the heart-lung machine opened a floodgate of innovation. With the time barrier relieved, the surgical treatment of heart disease now became limited only to the ingenuity of surgeons in developing effective operations.
I believe that the 1960s were the most productive decade of the century for thoracic surgery. A majority of the cardiac surgical procedures performed today were originated then, including prosthetic heart valve implantation, coronary bypass grafting, and cardiac transplantation. Although overshadowed by the excitement in cardiac surgery, general thoracic surgery made gains in experimental lung transplantation, new methods for staging malignancies, and esophageal antireflux operations. Those of us who practiced or trained in the 1960s will recall the almost constant introduction of new techniques and procedures and the abundance of financial support for the research that made them possible.
In the United States, the decade of the sixties was one of great ambitions and frustrations, of rapid technological progress, and of profound social change. President Kennedy proposed to put a man on the moon and this was accomplished in 1969. President Johnson declared a campaign against heart disease, cancer, and stroke; and in 1965 Congress established the Medicare and Medicaid programs. But an unpopular war in Vietnam stirred antiwar militancy, which escalated to widespread social unrest and rioting in the cities. In this atmosphere the public’s confidence in government and virtually all other institutions of authority weakened. The Medicare program quickly exceeded its projected costs, and against a background of inflation and dissent the American health care delivery system first began to come under criticism.
The decade of the 1970s was one of unprecedented expansion in clinical medicine despite concerns about the increasing cost of health care. Dissatisfaction with the health care system resolved into a perceived shortage of physicians. Congress responded by passing legislation that brought into being 25 new medical schools and doubled the number of recent graduates. Demand for coronary bypass surgery resulted in the opening of 100 new surgical units in the United States [2]. The number of thoracic surgeons increased from about 2,300 at the beginning of the decade to about 3,300 by its end [3]. Government money continued to be poured into medical research and, under a system of cost-plus reimbursement for Medicare, a new medical-industrial complex, which accelerated the introduction of new technology, evolved. This expansion of medical services fueled medical inflation and, together with general inflation, caused national health expenditures to more than triple, from $73 billion in 1970 to $247 billion in 1980 [4]. The 1970s ended with unchecked inflation and a severe economic recession.
Rapid growth in national health care expenditures in the 1980s caused government to introduce constraints on Medicare spending, beginning with the hospital sector. In 1982, Congress passed legislation that eliminated cost-based payment and substituted a prospective-pricing scheme. Hospitals thereafter were paid on a per case basis determined by the diagnosis-related group into which patients were classified by clinical diagnosis or procedure. As inpatient revenue declined hospitals expanded their outpatient services, which resulted in lower bed occupancy rates, fewer admissions, and shorter lengths of stay. With fewer and sicker patients occupying hospital beds, hospital operating margins decreased and Medicare payments per discharge failed to keep pace. Costs were shifted to the private insurance programs paid for by business and individual patients. These moves fueled the public’s growing dissatisfaction with the health care delivery system and promoted the development of managed care.
The success of hospital payment reform in limiting the growth of Medicare hospital expense led the government to seek ways to limit payment for physicians’ services to Medicare patients. After a series of freezes, caps, and reductions in payments for physicians’ services, in 1989 Congress passed comprehensive payment reform legislation. This reform resulted in a new Medicare fee schedule that eliminated payment based on historic charges and substituted one constructed on a resource-based relative value scale (RBRVS). Meanwhile, a move toward managed care and capitated prepaid insurance grew as the result of concern over the rising costs of medical insurance. Although general inflation was brought under control, medical inflation was not. The annual per capita cost of health care in the United States increased from about $1,000 in 1980 to over $2,000 by the end of the decade, whereas total national health care expenditures increased from about 9% of the gross domestic product to over 12% [4].
Many innovations in thoracic surgery were introduced in the 1980s, including lung and heart-lung transplantation, techniques for tracheal resection and reconstruction, improved devices for mechanical support of the failing heart, new concepts and techniques for the repair of heart valves, surgical treatment for cardiac arrhythmias, and better operations for complex congenital cardiac malformations. Improved protection of the myocardium during heart operations led to more operations on patients previously thought too old or too sick for surgical treatment. We are too close to the 1990s, perhaps, to recognize all of the major advances in our specialty during the past 9 years. However, I think that in time the introduction of video-assisted techniques of thoracic surgery, lung volume reduction for certain patients with emphysema, and the minimally invasive approaches to cardiac surgery will all be acknowledged as important contributions in this decade.
We have seen how economic and political change increasingly influenced the practice of thoracic surgery in the second half of this century. In this past decade, the forces of technology and government have required that we act together as never before. The Society of Thoracic Surgeons has grown and expanded to meet the challenges of a highly organized and complex health care environment. In addition to its traditional activities of meetings and scientific publications, it has become the voice of thoracic surgery within organized medicine, the representative of the profession to government, and the originator of programs designed to improve clinical practice. Politics, computer technology, and modern communications are domains in which we were not formally trained, yet these domains have dominated the energies of the society during the past decade and particularly during my year as President. I offer the following account with deepest thanks to all of you who have labored so well in these areas.
Government relations
The Society’s government relations efforts began shortly after Congress passed sweeping physician payment reform legislation in 1989. The intent of reform was to reduce physician payments under Medicare and to redress the grievances of primary care physicians who considered their services undervalued. Congress directed the Health Care Financing Administration (HCFA) to develop a resource-based relative value fee schedule based on estimates of work, practice expense, and the expense of malpractice insurance. The Society developed relative work values for thoracic surgery, but HFCA manipulated the scale so that the values for the high work-intensity procedures performed in our specialty were compressed and lowered in value. When the fee schedule was implemented in 1992 no one in medicine was happy with it.
Meanwhile, the practice expense and malpractice insurance components of RBRVS were allowed to remain at levels charged historically. This moderated potential payment reductions because practice expense accounted for a substantial proportion of payments, about half in thoracic surgery and even more in other procedural specialties. In 1994, Congress directed HCFA to place the practice expense component of RBRVS on a resource basis beginning in 1998. Initially, HCFA attempted to survey medical practices, but the effort failed. Next the agency convened panels of physicians from all areas of medicine to assist in the estimation of the direct costs of practice. HCFA’s methodology, instead of estimating actual practice dollar costs, required estimation of the amount of time each practice employee spent in direct contact with an "average" patient. This unrealistic bottom-up approach to expense estimation by only a few people from each medical and surgical specialty was unlikely to generate accurate estimates for the entire medical profession.
When HCFA announced its new practice expense relative value scale in January 1997 the results were shocking. The payment reductions for the most commonly performed thoracic surgical operations ranged from 40% to 50%. Reductions of this magnitude would have seriously jeopardized the provision of thoracic surgical services to Medicare beneficiaries and ultimately jeopardized the quality of care provided to all of our patients. The Society and its members reacted quickly to this threat. Under the leadership of President George Kaiser an unprecedented effort in public affairs was organized that came to involve each one of us. We voted to levy a special assessment upon ourselves. A grass roots legislative campaign was organized to alert congressional representatives to the adverse effects of payment reduction. We joined forces with other specialty societies, forming the Practice Expense Coalition. Consultants were hired to help us develop critiques of the HCFA methodology and to assist us in making key legislative contacts in Congress. Many of you made visits to Capitol Hill to apprise your senators and congressmen of the situation. In June 1997, HCFA announced revised estimates for practice expenses that for thoracic surgery still meant 30% to 40% reductions in payments.
Prompted by concerns over the effects of payment reform on access and quality, Congress passed the Balanced Budget Act of 1997. This law delayed the January 1998 implementation date by 1 year, required a 4-year phase-in for the changes, and required HCFA to reevaluate their methods for practice expense calculation. It also directed the General Accounting Office (GAO) to review HCFA’s methodology and report back to Congress.
When I assumed my duties as President of the Society in January 1998, I inherited a well-organized and well-financed political action campaign headed by Dr Timothy Gardner, Chairman of our Public Affairs Committee and staffed by our Washington office led by Mr Robert Wilbur. So many of you became politically active in this campaign that I cannot recognize you individually but I must mention the efforts of Dr Meredith Scott who not only organized political action in the state of Florida but brought together many state groups throughout the south. Together these surgeons reached their Senators and Representatives on key congressional committees with two messages, first, that drastic changes in Medicare payments for physicians’ services could reduce both access to and quality of care for Medicare beneficiaries, and second, that HCFA’s methodology in assigning practice expenses was not in compliance with Congress’s original intent that reimbursement be based on actual practice expenses.
In February 1998, the GAO report to Congress confirmed criticisms of HCFA’s methodology and recommended the use of practice survey data as a validity check on estimates. At about the same time, the Practice Expense Coalition and its consultant, the accounting firm of Coopers & Lybrand, presented an alternate method for the determination of practice expenses to the HFCA. This method came to be known as the top-down approach because it begins with actual practice expenses obtained through existing data sources. The best of these sources is the Socioeconomic Monitoring System of the American Medical Association. The Socioeconomic Monitoring System contains actual practice expense data drawn from a yearly survey of about 4,000 practices representing the spectrum of physician specialties. Taking these surveyed expenses for each specialty as a starting point, HCFA could then determine Medicare’s share to each service by using its existing physician payment data. This top-down approach was firmly grounded in the reality of actual total practice expense in contrast to HCFA’s original bottom-up approach that depended on unreliable estimates of the expense generated by individual services.
In March, Dr Timothy Gardner testified before the Senate Appropriations Subcommittee on the need for HCFA to consider the Coopers & Lybrand methodology. As a result, Senator Specter, the committee chairman, arranged a meeting between physician organizations and HCFA to further consider this method. Finally, in late March, Secretary Shalala of the Department of Health and Human Services, submitted a report to Congress in which, for the first time, it appeared that HCFA was considering the use of existing practice expense data sources to validate its estimates.
The Health Care Financing Administration was slated to release a new proposal for Medicare practice expense relative value units in May. In anticipation of the need for further congressional action, the Society scheduled a fly-in to Washington DC on June 2nd. When we arrived, a new and revised HCFA proposal was awaiting us. Overall, thoracic surgery would have reductions of 14%, to be phased in over 4 years beginning January 1, 1999. Moreover, in developing the new values, HCFA had adopted the top-down approach recommended by the specialty societies and had used data from the American Medical Association’s Socioeconomic Monitoring System survey to establish total costs for each specialty. When HCFA announced final practice expense estimates in November, we learned that the reduction for thoracic surgery had decreased to 12%, to be phased in at 3% per year beginning in 1999.
At present we can claim a partial but significant victory in the battle of practice expense payment reduction. Nevertheless, HCFA will continue to refine the interim values published this year as we move toward full implementation in 2002. This refinement process is not defined, but the society will remain fully engaged in it.
National database
The national database project was established by the Society in 1987 to give its members the tools to collect clinical data on their patients and risk stratify their treatment results for an accurate comparison to national outcome norms. It includes information on over 1 million patients contributed by about 450 surgical practices. At present, it is in a stage of marked transition. The following account is offered in the hope that participants will continue their support so that the national database can continue as a valuable resource for practice evaluation and improvement.
From the beginning, Summit Medical Systems, Inc provided the society-approved software used by most of the participants and also acted as the database manager. As manager, Summit obtained data each year from the participating sites and produced customized reports to the participants and an annual report on the aggregate data. Expenses were nominal because the costs of data gathering and database maintenance were recovered through yearly software license and participation fees. Separate databases for congenital heart surgery and general thoracic surgery developed more slowly because of greater clinical complexity and a weaker imperative for data collection in these areas.
By 1997 the arrangement with Summit was no longer meeting the needs of the Society for access to the latest advances in database technology, validation, and analysis. Therefore, the council of the Society approved a plan whereby the functions of software vending and database management would be separated. Specifications for data warehousing, including the functions of data collection, management, and analysis, were developed and a request for proposals was circulated to potential service providers.
These initial steps have led to a complete restructuring of the national database by the extraordinary effort of staff, key members, and Society officers during the past year. A team led by Dr Peter Pairolero and consisting of Drs Stan Dzuben, Bruce Ferguson, Laurie Shroyer, Fred Edwards, Fred Grover, and Ms Mary Eiken conducted the data warehouse selection process. The selection criteria included a hardware capability for further growth of a database that already exceeded over 1 million records, a technical staff of sufficient size to provide good service, on-site analytic expertise, and an ability to facilitate the transfer of existing data. Seven data warehouses responded to the request for proposal from which three were selected for site visits in April. In May, on the recommendations of the team, the council agreed to enter negotiations with the Duke Clinical Research Institute located at Duke University. During the summer and early fall, the team worked intensely with Duke to develop the contract and a scope of work that spelled out in detail the Society’s expectations. Finally, in November the council approved the contract and this complex process was brought to a successful conclusion.
Meanwhile, in June, Summit unexpectedly announced its decision to discontinue development and marketing of its software. It offered to continue support for its Windows-based product until June 1999 thus giving the majority of database participants time to acquire new software. This immediately challenged the society to identify and promote alternate software options.
Fortunately, the Society could act quickly and in early August offered a request for proposal to software developers. This was made possible by the work of Dr Bruce Ferguson who had previously standardized the data definitions in a collaborative project with the American College of Cardiology and by Dr Stan Dzubin who had worked these new definitions into a "core" data set containing the most critical data elements and had then produced the first fully documented description of the database. By November ten companies had responded and were in the process of developing software.
The Society’s national database is unique and truly a national resource. The transition from the old system to the new is evolving and the transition team has done a magnificent job in bringing this project to its present state. Their efforts are deserving of our continued support as the national database moves toward fulfilling its full potential.
Internet
The joining of the personal computer with modern telecommunications technology is profoundly changing our culture. The near instantaneous ability to communicate and exchange information through the Internet not only affects each one of us individually, but changes the relationship between virtually all organized elements of society. The story of the Society’s deployment of this technology is a story of rapid technological change, risk taking, and extraordinary effort.
The Society’s Internet project began with the Presidency of Dr Robert Replogle, whose vision was that of a worldwide community of thoracic surgeons linked through the Internet for purposes of communication and education. The enterprise was launched with the appointment of Dr Peter Greene as Web editor and with the enthusiastic support of Dr Thomas Ferguson who brought on-line our journal, The Annals of Thoracic Surgery. During the presidency of Dr George Kaiser, an agreement was signed with the Community of Science (COS), a Web-based publisher of scientific databases, to publish Internet materials.
A Web page for the Society was initially developed by Dr Greene. Next, with the assistance of COS, the effort was broadened by creating CTSNet, a Web site linking the home pages of the major cardiothoracic organizations around the world. This site contained information resources enabling surgeons to communicate with colleagues, explore on-line medical journals, engage in discussions, and have access to a vast repository of information. By last May, slightly more than a year after its inception, the CTSNet web site listed the names of over 10,000 thoracic surgeons worldwide and had received over 3,000,000 hits or visits to the site. Eleven national and international thoracic surgical organizations had signed on as participants and six others were in the process of doing so.
With the growth of CTSNet, several of the larger participating organizations expressed their desire to participate in the governance of CTSNet and thereby gain a voice in its future while sharing in its expenses. Up to this point, the society had underwritten the development costs. It also had obtained sponsorship from industry for educational enhancements to the site, including text book publication, a residents’ page, and a controversies section. Sponsorship money went to COS for publishing material provided by the editorial office and COS supported the editorial office. Nevertheless, the society incurred considerable ongoing expenses for the maintenance of CTSNet, and revenues to defray these expenses had not been forthcoming.
In June, I was contacted urgently by Peter Greene, the Web editor, who informed me that the COS had announced that they were moving their activities from a shared computer to which the editorial office had access to their own computer to which it would not have access. This change would create insurmountable problems for the editorial office in maintaining files and would prevent the editor from introducing enhancements made possible by the rapid advance of Internet technology. He recommended that the society sever its relationship with COS and transfer the bulk of publishing activities to the editorial office.
In view of the existing contract with COS and the agreements with the CTSNet participants, the decision to leave COS was difficult. However, in July the Executive Committee directed society representatives to begin negotiations, and COS agreed to transfer publishing responsibilities. Over the next month a myriad of technical, legal, and financial issues were addressed. When the Executive Committee conferred in August, most of the technical and legal issues had been resolved. A firm date for transfer of the files and going live on the new site awaited settlement of the remaining financial issues. Negotiations over money often take time and this one was no exception. After weeks of discussion a satisfactory arrangement for both parties was reached in late October and a final agreement was signed. On November 2, 1998, CTSNet was published by The Society of Thoracic Surgeons on its new server. All of the functions of the original CTSNet has been preserved in the transition, and new infrastructure enhancements have been added. But what about the future?
At the European Association for Cardio-thoracic Surgery meeting in Brussels in September 1998 there were renewed calls for a sharing of the governance between the society and the other major professional organizations. In response to this need, the council of the society at its October meeting agreed that the society retain a majority ownership in CTSNet but allow other major thoracic surgical organizations to purchase the remainder. A restructuring plan along these lines is under consideration at this meeting and if accepted will not only relieve the society of a considerable burden on its resources, but will ensure the viability of CTSNet and its important functions well into the next century.
Century’s end
Thoracic surgery at century’s end has achieved an envied place in the house of medicine. As thoracic surgeons, we are the winners in the lottery of life. Graced by birth and aptitude we learned to apply the hand work and the mind work of surgery in the care of the sick. For this we have been richly rewarded. Foremost, we have been given a priceless gift: the satisfaction that comes from sustaining human life by our own efforts. As we look back on progress in thoracic surgery and change in society during the 20th century it seems to me that there are four elements that we must carry forward into the 21st century to meet its inevitable challenges.
The first of these is the spirit of innovation. Throughout the present century innovation more than anything else has brought thoracic surgery to its present state. Today there is no lack of need for innovation. Patients still die from postoperative low cardiac output, cancer recurs, and transplanted organs all too soon lose function. We no longer have the professional autonomy that allowed our predecessors to try new things independently. Both managed care and evidenced-based practice threaten to stifle innovation. We must continue to promote innovation by recognizing and supporting young investigators through such means as our financial support to the Thoracic Surgery Foundation and its scientific grants. More collaboration with industry will bring better instruments and devices. Better communications through the Internet should facilitate our collaboration in clinical trials of processes and procedures. We must emerge from our competitive environment and create a cooperative one.
Second, we must remain adaptable to social changes that do not threaten the welfare of our patients but seem to threaten our own prerogatives. The growing public demand for accountability through performance measurement is a case in point. Because of dissatisfaction with managed care there is a scramble to measure and rank clinical outcomes in all areas of medicine. Organizations from the Joint Commission on Accreditation of Health Care Organizations to the American Medical Association and its AMAP program are developing measurement systems. Even the American Board of Medical Specialties is studying ways to introduce competency testing into the certification and recertification processes. You can find your hospital’s coronary bypass results in Medicare patients ranked on the Internet. As thoracic surgeons, we have recorded, tracked, and analyzed our results as perhaps no other specialty has done. I believe that now is the time to make our results readily available to our patients and to the public. These results should be properly stratified for patient risk, compared with the benchmarks of the national database, and described in terms that account for random variation. Public inspection of results under these circumstances should give few of us anything to fear. Faulty rankings by parties using faulty data and poor analysis hurt us all.
Third, organized thoracic surgery should remain as presently constituted. Specialization in medicine has been a major factor in the scientific advances of the past half-century. Thoracic surgery itself has been increasingly divided into areas of general thoracic, adult, and congenital cardiac surgery. Even further subspecialization has caused some to describe themselves as esophageal surgeons or minimally invasive cardiac surgeons. To concentrate in a narrow area in order to increase proficiency and advance knowledge is a legitimate action that could benefit patients. However, if it is accompanied by a divorce from the main body of the specialty, it can have pernicious effects. Defections of specialized groups of thoracic surgeons diminish the specialty as an entity. Thoracic surgery is already one of the smallest recognized specialties. Contrast, for example, the 4,000 members of this society with the 24,000 members of the American Academy of Ophthalmology, the 35,000 members of the American Society of Anesthesiologists, or the 80,000 members of the American Academy of Family Physicians. Despite our size, our voice in public matters that concern our patients has been strong and effective. It can only remain so if we resist fragmentation and remain together.
Finally, the most important element that we can bring to the next century is our focus on patients. Now and in the future the greatest ethical dilemma we shall face is between what is good for the individual versus what is good for society. Richard Lamm, in a recent article entitled "The coming clash: patient advocates vs. the public interest," defined this conflict well [5]. He argues that to do everything beneficial for every patient is economically unsustainable and that physicians must accept the concept of limited resources and forego some medical care in order to maximize the health of the group. This concept, of necessity, has been adopted by those who control the distribution of public resources for health purposes. Governmental constraints placed on health care spending during the past 20 years can be expected to accelerate in the new century. Moreover, we must now contend with a private insurance industry that seeks to limit treatment in order to maximize profits. Neither influence will stop the advance of technology and the expenses it brings. How then, as physicians unwilling to give up our 2,000-year-old ethic of the best possible treatment for each patient, are we to respond? We must remain advocates for our patients and engage in the public dialogue about resource allocation. We must ensure that the treatment of life-threatening disease remains on the top of the priority list and is not displaced by marginal medicine that seeks only to smooth out the bumps of normal life. We must find and support better alternatives to for-profit health care delivery systems. In making our case, we must evaluate new treatments and demonstrate that they are indeed appropriate and result in saved lives and reduced suffering. In the final analysis, it is the public and not the health policy makers who will decide the limits of health care spending. Our obligation is to see that the public thoroughly understands the benefits that we bring.
At century’s end we can look back with gratitude to the innovators in thoracic surgery, their heroic patients, and our culture, which placed a high premium on medical research and the treatment of the sick. We can look forward to the new century with the hope that many of the diseases that we now treat will be eliminated. Meanwhile, there is a world of work and opportunity awaiting us. Let’s go.
References
This article has been cited by other articles:
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  J. E. Mayer Jr Is There a Role for the Medical Profession in Solving the Problems of the American Health Care System? Ann. Thorac. Surg., June 1, 2009; 87(6): 1655 - 1661. [Full Text] [PDF]
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