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Ann Thorac Surg 2000;69:1303-1311
© 2000 The Society of Thoracic Surgeons
a Missouri Baptist Medical Center, St. Louis, Missouri, USA
Address reprint requests to Dr. Kouchoukos, Cardiac, Thoracic and Vascular Surgery, Suite 266C, 3009 North Ballas Rd, St. Louis, MO 63131
e-mail: ntkouch{at}aol.com
I wish to thank the members of The Society of Thoracic Surgeons for the honor and the privilege of serving as your president for the past year. I am particularly thrilled to have the opportunity to deliver this address at the dawn of the new millennium and of the 21st century. The specialty of cardiothoracic surgery has existed for approximately 100 years, the entire span of the 20th century. During that century, and particularly in the past 50 years, extraordinary progress and remarkable achievements have occurred in virtually every aspect of our specialty. I have been extremely fortunate, as have the other cardiothoracic surgeons of my generation, to have spent my entire professional career in the last half of the 20th century, and to have witnessed many and participated in a few of these achievements. The 21st century holds promise for even greater accomplishments and technological advances, and I am envious of the generations of cardiothoracic surgeons that will spend their entire careers in it.
All of us, at one time or another, have been nurtured and supported by individuals who have truly made a difference in our lives. The close and often intense interactions between teacher and student that characterize the teaching of medicine, and of clinical surgery in particular, have made this possible. Many of us have been privileged to stand on the shoulders of giants, and I put myself in that category. I would be remiss in not acknowledging those individuals who have profoundly influenced my life and my career as a cardiothoracic surgeon.
My parents, Thomas and Antoinette Kouchoukos, in addition to providing love and emotional support, made it possible for me, in times that were far less prosperous than the present, to complete my graduate and postgraduate medical studies free of economic encumbrances or other burdens. This, I have come to realize, was a truly magnificent gift.
Carl A. Moyer was the Chairman of the Department of Surgery at Washington University where I was a medical student and a general surgical intern and resident. He was a stimulating, challenging, and provocative teacher who was deeply committed to teaching the science of surgery, as well as the technical aspects, to his students and residents. His knowledge and love of physiology and his ability to demonstrate its relevance to clinical surgery, which he began to do during the second year of medical school, stimulated me and a number of my classmates to become surgeons.
David Goldring was Professor of Pediatrics at Washington University and one of the first pediatric cardiologists in North America. I had the privilege of working in his laboratory and in his clinic as a medical student, where I was first exposed to the surgical treatment of congenital heart disease. He was a compassionate and dedicated physician, and he encouraged me to pursue cardiac surgery as a career. He was a mentor in every sense of the word.
Harvey R. Butcher, Jr, was Professor of Surgery at Washington University. A superb clinical surgeon, he taught his residents, among other things, how to operate safely on major blood vessels, how to treat cancer aggressively, and how to apply statistical methods to clinical surgery. He relished technical challenges and was the backbone of the residency training program in general surgery at Washington University in the 1960s and 1970s. I had the good fortune to work closely with him for a year after completing my residency in general surgery. He was a superb role model for surgical residents and junior faculty.
These three physicians are likely not familiar to most of you. However, I am certain that each of you could identify individuals like them who guided you through the formative years of your surgical careers and had an impact on the way in which you practice cardiothoracic surgery.
Thomas B. Ferguson is known to all of you, a distinguished past president of The Society of Thoracic Surgeons and the editor of The Annals of Thoracic Surgery for the past 15 years. I had the opportunity to learn general thoracic and cardiac surgery from him as a student and as a resident, and I have been learning from him ever since.
John Kirklin is also known to all of you, and is one of the true giants of cardiothoracic surgery. His scholarly and uncompromising approach to cardiac surgery has had an enormous impact on our specialty. His commitment to teaching and to training cardiothoracic surgeons and his many pioneering scientific contributions are widely recognized. I was extremely fortunate to have spent 14 years working with him and learning from him at the University of Alabama at Birmingham.
I have been associated with a number of outstanding colleagues in the four institutions in which I have worked during the past 3 decades, and they are too numerous to mention individually. However, I would like to acknowledge my current colleagues with whom I practice cardiovascular and thoracic surgery, John Connors, J. Peter Murphy, Jr, and Michael Murphy. They have been most supportive of my commitment to The Society of Thoracic Surgeons and tolerant of my absences from the practice during the past year.
Finally, I want to acknowledge my wife, Judy, and my three sons, Nicholas, Robert, and Thomas, of whom I am extremely proud. They have brought much happiness into my life. Judy has been an enabler in the finest sense of the word. Her support, her sacrifices, her eternal optimism, and her cheerful assumption of many family responsibilities have made it possible for me to pursue my professional interests to the fullest. She has also taught me much about life and love.
These are exciting times to be engaged in the practice of cardiothoracic surgery. Technological breakthroughs occur on an almost-daily basis. Molecular biology is rapidly making its way into our specialty. Advances in bioengineering will, in the not-too-distant future, likely result in the generation, from primitive cells, of tissues such as blood vessels, valves, and heart muscle, and possibly even whole organs, including hearts and lungs, that will be implanted into humans without being rejected. Permanent mechanical hearts and possibly even immunogenically modified xenograft hearts, lungs, and other organs will likely become available for implantation in the next few decades. Robotics and other technical innovations increasingly are being incorporated into our practices.
Life expectancy has increased almost 30 years during the past century, and the potential exists to increase it even more in the 21st century. Death rates from coronary heart disease and stroke have declined dramatically in the past 50 years, and surgery has played an important role in reducing these death rates (Fig 1) [1]. More importantly, perhaps, there is, in this century, the enormous potential to increase the quality as well as the quantity of life. The future of medicine and of our specialty appears to be incredibly bright.
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The number of applicants to United States medical schools declined 18% between 1996 and 1999 (Fig 2) [4]. Prospective students who were interviewed cited concerns about the future loss of autonomy and income under managed care and reservations about the high costs and levels of debt they would incur to finance a medical education.
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This is one of a number of paradoxes that American medicine and cardiothoracic surgery must resolve as we enter the new millennium. I wish to discuss several other paradoxes that we must forcefully address and attempt to resolve if our profession and our specialty are to flourish in this new century. These dilemmas relate to issues in the areas of education, technology, ethics, and public policy. I will also offer some suggestions for their resolution. A paradox, as defined in the Random House Dictionary of the English Language is "a statement or proposition seemingly self-contradictory or absurd, but in reality expressing a possible truth" [8].
Education
Paradox
The cost of obtaining a formal education in cardiothoracic surgery has increased substantially, yet subsequent compensation and thus the ability to recoup these costs or to repay the debt incurred is steadily decreasing.
I already cited the significant and ever-escalating costs of an undergraduate medical education. In 1999, we surveyed 448 cardiothoracic surgeons who recently completed the certifying examinations of the American Board of Thoracic Surgery. Two hundred fifty-one of them responded, for a response rate of 56% with a margin of error of ±4% at the 95% confidence interval. Among the 251 respondents, the mean debt incurred for their undergraduate and medical school education was just over $51,000. An additional educational debt, which averaged just under $28,000, was incurred during general and cardiothoracic surgical training, for a total of almost $80,000 (Table 1).
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The number of applicants to the National Resident Matching Program for Thoracic Surgery has decreased 11% in each of the past 2 years when compared with the preceding year (1998). In the past 3 years, the number of applicants who are graduates of United States medical schools has been less than the number of available residency positions. In 1999, only 116 such individuals applied for 139 positions [9]. The costs and length of training are likely contributing factors to this decline in applicants.
Cardiothoracic surgeons in the middle years of their professional life spans are facing decreased reimbursement and reductions in income that have affected not only their standard of living but, more importantly, their ability to retire their educational debt (Table 2) [7]. As a result, some are seeking nonclinical careers in administration, business, communications, and education.
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To complicate this dilemma further, the changes that have occurred in many academic health centers have resulted in longer working days for many residents and less time for didactic or clinical teaching and for laboratory or clinical research. Furthermore, the reductions in funding and the alterations in funding sources for graduate medical education that have been proposed by the federal government could make it difficult or even impossible for many academic health centers to fully fund residency training positions in cardiothoracic surgery in the near future.
What can we, as practicing cardiothoracic surgeons and educators, do to resolve these educational paradoxes and to assure the public and our patients that well-educated, well-trained, and highly competent individuals will be available to meet their cardiothoracic surgical needs in this new century? In the United States, the duration of formal cardiothoracic surgical training should be increased to a minimum of 3 years for all programs. This has been done already in Canada and other countries. Currently, only 19% of our residency programs require 3 years of training.
The duration of general surgical training should be reduced by at least 1 year and possibly more so that the overall length of training required for board certification in thoracic surgery is not increased, and the already huge financial burden that many residents incur is stabilized or reduced. The American Board of Thoracic Surgery recently has taken an important step by voting to eliminate, at some future time, the requirement for board certification in general surgery as a requirement for certification in thoracic surgery, thus creating the opportunity to reduce the total number of years of residency training.
The issue of increasing the length of cardiothoracic surgical training and reducing the length of general surgical training has been debated intensively during the past 10 years, and no consensus has emerged from the various organizations that represent our specialty and are involved in cardiothoracic surgical education. The American Board of Thoracic Surgery has taken the important first step and others should follow. The time has come to question seriously whether the model for cardiothoracic surgical training that has been so successful for the past 50 years will be appropriate for the 21st century.
The education of cardiothoracic surgical residents must receive greater emphasis. This is a particularly difficult challenge because of the changes that are occurring in the operation of hospitals in America, and I suspect, in other countries as well. Economic pressures, particularly in academic health centers, have forced many hospitals to reduce the number of employees who provide care to patients. Some of the workload of these employees has been shifted to residents who are, in many instances, already overburdened with tasks that have little or no educational value.
The Thoracic Surgery Directors Association is greatly concerned about the education of cardiothoracic surgical residents and has formed several committees to establish and implement a requisite curriculum for them. Computer-assisted and Internet-based learning activities will be an integral part of this process and will be used extensively to enhance the educational experience of residents. With CD-ROMs, web sites, and other information technology, it will be possible, for example, to offer to all residents exposure to lectures and demonstrations by prominent cardiothoracic surgeons and surgical scientists. These educational activities would be done when it is convenient for the resident. This is an exciting concept, and it represents a concerted effort to define and implement a more structured thoracic surgical curriculum than presently exists.
A more organized, comprehensive, and continuous postresidency educational process must be implemented for our specialty. Residency training is only the beginning of the educational experience that must continue for the professional lifetime of a cardiothoracic surgeon. New concepts, new procedures, and new techniques must be learned and mastered. Physicians in highly technically oriented specialties such as ours will soon be required to provide verifiable evidence of continued competence. This will require major changes in our postgraduate educational activities and will involve use of the electronic media to a much greater extent than has occurred in the past. It will also likely require wider use of fellowships, preceptorships, and possibly even apprenticeships, as well as the establishment of formal learning centers. Recertification of practicing cardiothoracic surgeons by the American Board of Thoracic Surgery, which is required in the United States only every 10 years, currently represents the only documented evidence for systematic postgraduate learning that includes an examination process. In the near future, this recertification will be insufficient evidence for adequate postgraduate educational activity.
Although all of these changes and others will be necessary in the coming years to assure our patients that they have access to the best cardiothoracic surgical care, we must not abandon those methods for the teaching of cardiothoracic surgery that have endured throughout the first 100 years that our specialty has been in existence.
One of the most important of these methods, I believe, is the one-on-one interaction that exists between teacher and student and is exemplified by the relationship between clinician-teacher and medical student, senior resident and junior resident, attending surgeon and resident, and between the senior surgeon and the young surgeon in a cardiothoracic surgical practice. These relationships provide the unique opportunity to transmit to our younger colleagues not only scientific knowledge and surgical precepts, but also values, the beliefs we hold about what is important, including the patient-physician relationship, the dangers of managed care, the need to maintain our professionalism, the commitment to persist until the job is done, the willingness to give back something to society, such as free care for those who are in need of it, and the adherence to a higher code of ethics than that expected of society as a whole. We must, as teachers of our younger colleagues, focus less on our rights and more on our responsibilities. Donald Kennedy, the former president of Stanford University, has termed this "academic duty" as opposed to "academic freedom" [10].
Mentoring must be an important part of this responsibility or academic duty. Despite our disillusionment, disappointment, and despair about how the practice of medicine has changed, we must not let this interfere with our obligation to nurture our younger colleagues and impart to them the joys and the wonders of our specialty and the gratification that comes from commitment, persistence, and hard work.
Conveying to our younger colleagues our unhappiness and frustration about what is happening to the practice of medicine, to our levels of reimbursement, to our loss of control over clinical decision making, and about the continuing challenges to our ethical and moral principles will impair our ability to attract the best and the brightest young men and women to our specialty and will do little to inspire and stimulate them. We must remain positive role models and committed mentors if cardiothoracic surgery is to flourish in the new millennium.
David Halberstam, the noted journalist, has written a book about Michael Jordan, the greatest professional basketball player of all time. In a commentary in Time magazine about his book, he reflects on how, when Jordan was playing college basketball at the University of North Carolina, Dean Smith, his coach, recognized his great physical ability and his hunger for the game. But he also recognized his deficiencies, and he coached him to add all of the other things that became so critical to his greatness. Halberstam concludes that "as such, Jordan is a reminder to us of something that is desperately undervalued in contemporary America: the value of a real apprenticeship for even the most talented of people" [11].
Technology
Paradox
In this new century, the continuing surge in biomedical and technologic achievements will result in dramatic improvements in the prevention, diagnosis, and treatment of disease, yet the fiscal resources to fund these advances are shrinking in the public sector, and support for relentless progress is less than unanimous.
Some health policy experts and ethicists argue that such progress should be dampened because the principal cause of increasing health care costs is new technology. Others argue that major scientific and technical advances will rescue our faltering health care system by eliminating most of the important causes of illness, possibly extending the healthy life span by 30 to 40 years and greatly reducing the need for medical services [12]. These opinions represent the extremes, and the ultimate solution will be somewhere between them. All biomedical progress, however, cannot and should not be bundled into one category. Some advances might result in increased costs in one aspect of care and at the same time reduce costs in another area. Some will actually reduce total costs.
What can cardiothoracic surgeons do to address this dilemma? It is becoming increasingly necessary and important to provide data on the outcomes of various therapeutic interventions, including the highly technical surgical procedures we perform, in order to demonstrate their effectiveness and justify their continued use. Payors and patients are appropriately demanding this information so that they can obtain the greatest value for the dollars they spend on health care.
The Society of Thoracic Surgeons has led the way in this endeavor by establishing a database of cardiac and thoracic surgical procedures that has become the gold standard and will likely remain the major repository of information relating to the practice of cardiothoracic surgery in the United States. We must persist in our efforts to acquire high-quality outcome data and to disseminate it to our members; to federal, state, and regional governmental agencies; to health care providers and payors; and even to patients and their families. We have the almost unique ability to document and demonstrate which therapeutic interventions are effective for a number of major health problems, including coronary artery disease, valvular heart disease, congenital heart disease, and lung and esophageal malignancies. We must demand and continue to provide evidence-based data about what we do and why we do it. We must also be willing to abandon therapies that are shown to be of no appreciable value. Maintenance of our national database is essential to these efforts. It is an expensive undertaking and our Society has invested millions of dollars to establish and nurture it. We must continue to support it. It is imperative however, that we, as physicians, remain the owners of this information and that we strongly resist any pressure to relinquish the responsibility for data gathering and analysis to others.
We must partner with governmental agencies at all levels, and possibly even with healthcare delivery systems, to establish more effective methods to evaluate and control new technology that relates to our specialty. The collaboration of our Society with the Healthcare Finance Administration and the National Institutes of Health to evaluate the role of lung volume reduction surgery for the treatment of advanced emphysema is a prime example of such a partnership. Although it might not represent the perfect model, it nevertheless represents a major attempt to work with government to address a major health problem.
The Society, in collaboration with the Duke Clinical Research Institute, has recently been awarded a $1.5 million grant from the Agency for Health Care Policy and Research supporting a national initiative to evaluate and improve the quality of coronary artery bypass grafting in the United States. This represents the first federally funded grant ever awarded to a professional society by the Agency for Health Care Policy and Research.
The Food and Drug Administration has approached the Society to provide, from our national database, information on the utilization and risks of transmyocardial laser revascularization for advanced ischemic heart disease. These are examples of the ways in which our Society is working with government to evaluate technology and demonstrate its value.
We must increase our efforts to educate the public and our legislators about the risks of limiting the development of new technology. At the same time, we must be mindful of the costs of such development and be willing to abandon technologies that are shown to be of no value. Above all, we must remain optimistic about the future of medicine and vigorously support medical research. The future of our specialty depends on our ability to develop new and better ways of treating cardiothoracic disease. We must also speak out forcefully against waste and fraud in the delivery of health care and be willing to criticize openly and discipline those who abuse our health care delivery systems or defraud the payors.
Ethics
Paradox
By tradition, and dating back at least 2,500 years to the time of Hippocrates, the physician’s primary responsibility has been to the individual patient; however, the underlying principle of managed care requires that a physician not be an unrestricted advocate of the individual patient but must submit to the needs of the other members of the medical care organization. This paradox has created a moral dilemma for many physicians and has introduced considerable complexity, as well as the potential for serious conflict of interest, into the practice of medicine. The physician has become a double agent, a term used by Shortell and colleagues [13] to describe the phenomenon of representing the interests of both the patient and the medical organization. The physician thus resembles "a real estate agent who represents both the buyer and the seller, or a spy who is also a counterspy for another government" [13]. It is not a label that any respectable physician would wear with pride. However, unless there is total or near total collapse of the managed care concept for the delivery of health care, the pressure to place the needs of the organization above those of the individual patient will continue.
Shortell and colleagues [13] suggest that a new moral fabric will be required to maintain professional principles while meeting the needs of patients, purchasers of health care, and other groups. This new fabric reflects both a broader set of responsibilities and accountabilities for physicians and a sharing of these responsibilities with others. Physicians can no longer be the sole judges of what constitutes appropriate accountability. Those authors argue that if physicians do not step forward and respond to the increasing demands for accountability, the medical care organizations and external bodies will fill this void. We must, therefore, become more actively involved in this process but at the same time continue to protect the rights of our individual patients. This is new ground for most physicians and it must be explored cautiously. The pressures to adopt this new moral fabric will continue, and while we must be involved in the process, our commitment to the care of the individual patient must never be abandoned. We must remain the advocate of the individual patient.
How do we address these and other ethical concerns effectively? There is currently increasing interest and activity among physicians in this country to establish unions or (to use a more euphemistic term) national negotiating organizations, to protect the rights of patients as well as to protect physicians themselves from the ravages of managed care [14]. The American Medical Association has recently voted to establish a union that they have termed "Physicians for Responsible Negotiations" and which represents an alternative to traditional labor unions. Although initially it will represent only employed physicians and residents, a relatively small minority of the entire physician population, there is clearly strong support for the concept from the entire medical community. This organization will not strike or otherwise withhold care and will not recruit members. There is also legislation pending in Congress that will attempt to provide all physicians with a federal exemption to the existing antitrust laws and permit them to bargain collectively. The fate of this legislation is presently unclear.
These initiatives, if implemented, could give physicians a stronger voice in decisions that affect patient care and could provide protection from managed care organizations if, for example, physicians refuse to accept contracts that restrict access to optimal treatment or provide for unreasonable reductions in reimbursement. The temptation to organize specifically to protect only our personal interests, however, must be resisted. We should support only responsible and ethical collective negotiation. Ethical considerations must supercede economic considerations if medicine is to remain a true profession.
Christine Cassell, a respected bioethicist, has articulated the characteristics that define a learned profession. They are self governance, service to the poor, deliverance of quality, a high level of learning, autonomy, altruism, self-sacrifice, heroism, and ethical practice and public accountability [15]. None of these characteristics should be abandoned in the name of managed care, or whatever label is attached to the delivery of health care in this new century, if it intrudes upon the patient-physician relationship. Our professionalism is becoming increasingly endangered by perverse financial incentives, competition, and a decline in patient trust [16]. We must forcefully speak out about our values and remain ever mindful of the dangers of complacency and silence.
Public policy
Paradox
The United States is the wealthiest nation in the world and spends more money per capita for health care than any other nation, yet 44 million people (16% of the population) currently lack health insurance in our country. The number of uninsured Americans increased by one million in 1998, during a period of the greatest prosperity that this country has ever experienced. Many explanations have been offered as to why these numbers are increasing, including welfare reform, which has caused many individuals who have found employment to lose their Medicaid coverage and to be unable to obtain employee-based insurance, the increasing use of part-time workers throughout the economy, and the ever escalating costs of private health insurance.
The major groups that remain without health insurance include children (15% of the total), ethnic minorities (as high as 35% among Hispanics), 34% of the foreign born, and 25% of families with incomes of less than $25,000 per year (Fig 3) [17]. Some health policy experts speculate that little pressure for comprehensive guarantees of access to health care or for rejection of the free market, managed care approach to health care will occur until the number who are uninsured exceeds 25% to 30% of the population, which would be 65 to 85 million people. They argue that only a major catastrophic event such as a major economic depression, a world war or a disease pandemic, or the collapse of the managed care industry would result in comprehensive health care reform or universal coverage [18]. None of these calamitous scenarios is likely to occur in the foreseeable future, and thus a national solution to this problem in the form of a comprehensive, federally supported program is also unlikely in the near term.
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It is time for all physicians, including cardiothoracic surgeons, to use our still considerable prestige and influence to pressure our legislators to address and resolve this paradox in the near future rather than 20 or 30 years from now. We must enlighten the public, especially those individuals who are employed, who have adequate health insurance, and who enjoy good health, to understand that all Americans, including children, the poor, the unemployed, and the disadvantaged, are entitled to the same health benefits.
This year, 2000, is an election year in the United States. There will be ample opportunity for each of us to query the candidates for Congress, the Presidency, and for state office about health care issues and to financially support and vote for those who are willing to address and resolve this problem. Viable solutions have already been proposed by some of the candidates and by some professional organizations. The American Medical Association is one of these organizations, and it favors a pluralistic approach to the provision and financing of universal health care access rather than a single-payor system.
Cardiothoracic surgeons are a small group, numbering less than 4,000 in the United States, but we can partner with other professional societies, as we have in the past, into coalitions to state our positions forcefully in order to effect change. The activity surrounding patient protection legislation is an important example of how pressure from the medical profession and active involvement by physicians in the political process can make a difference. The Patient Access to Specialty Care Coalition, which is composed of over 100 medical organizations including the Society of Thoracic Surgeons, forcefully advocated and lobbied for the incorporation of six important principles into patient protection legislation, the so-called Patients’ Bill of Rights. These six principles were included in the Bipartisan Consensus Managed Care Improvement Act of 1999, which was passed by the House of Representatives during its most recent session. They include provisions that permit patients to appeal medical decisions of health plans, internal and external appeals processes, and the right to sue health plans under certain circumstances. Although the battle to enact this proposal into law is not over, this activity demonstrates that we can have an effect on legislation that affects the welfare of our patients. We can have a similar effect on the problem of universal access to health care by working with other advocacy groups to effect change. In addition to the benefits it provides to our patients, active involvement in advocacy of this type can be a potent antidote to the frustration and unhappiness we experience in our day-to-day professional activities.
There are other paradoxes in addition to the ones that I have discussed that involve our specialty and will demand our attention in this new century. They exist in other nations as well as in the United States. Living with paradox is never easy or comfortable. It is an inevitable part of our existence in a complicated world that is becoming even more so. To use a sports metaphor, "Life goes, you see, to golf’s own ditty; without the rough there’d be no pretty" [19]. We must find ways to make sense of these contradictions and inconsistencies and to use them to shape a greater future for our patients and for our profession.
Cardiothoracic surgeons are, by nature and by tradition, problem solvers and decision makers. The scientific and technologic achievements that have occurred in our specialty during the past 50 years and the effects that these advances have had on the quality of the lives of our patients are testimony to these attributes. There will be no dearth of challenges in this new millennium, although they will likely differ substantially from those of the past. The same personal qualities, however, will be required to resolve them.
Cardiothoracic surgeons represent an almost trivial percentage of the entire physician population. In order for us to accomplish our objectives, we must remain united under one banner, that of our specialty. We must resist the temptations to splinter and pursue our individual or special interests, which is precisely what our adversaries in the health care system want us to do. At the same time, we must partner with other specialties and organizations to address and successfully resolve the dilemmas that we will face in the future.
Challenges and opportunities
The Society of Thoracic Surgeons is in a unique position to address many of the challenges that face our specialty. It is one of the largest organizations of cardiothoracic surgeons in the world and includes members from over 60 countries. It has undergone unprecedented growth in the past 5 years. Between 1995 and 1999, the annual operating budget of our organization increased from $2.3 million to $6.3 million, an increase of almost 200%. The number of committees more than doubled, from 11 to 23. The number of individuals serving on these committees increased from 270 to 447. The staff at our headquarters in Chicago increased from 14 to 17 full-time equivalents. We estimate that, in 1998, the number of volunteered hours of service provided to the Society by its members was approximately 40,000! That is the equivalent of 20 individuals working full-time.
During this 5-year interval, the Society has increased, on an annual basis, the attendance of members, nonmembers, and exhibitors at our annual meeting. It has become a political force on Capitol Hill, providing testimony on important issues related to health care, forming coalitions with other professional societies to support legislation that will benefit our patients, and reversing the trend of declining reimbursement for professional services from Medicare. We have initiated a Political Action Committee, established a strong public relations and patient advocacy program, substantially expanded our database activities, and established a strong presence on the Internet, integrating the activities of our website with those of other thoracic surgical societies throughout the world through CTSNet.
We are partnering with the American Association for Thoracic Surgery, the American Board of Thoracic Surgery, the Thoracic Surgery Directors Association, and the Residency Review Committee to address issues related to thoracic surgical residency and postresidency education in the United States. We will collaborate with the American Association for Thoracic Surgery, the European Association for Cardiothoracic Surgery, the Thoracic Surgery Foundation for Research and Education, and other national and international cardiothoracic surgical organizations to address issues related to education, technology, outcomes analysis, conflict of interest, and ethics. We will continue to work with other professional societies to protect the rights of our patients and to provide them with appropriate and affordable health care.
All of this has been, and will continue to be, accomplished because of the commitment and dedication of the leadership of The Society of Thoracic Surgeons, which includes the Executive Committee, the Council, and the Committee Chairs, and through the diligence and hard work of the members of our various committees, a truly extraordinary group. Our staff at Smith Bucklin Associates has provided superb support for our many activities. It has been a privilege for me to work with all of these individuals during the past year.
As we begin the new millennium and the 21st century, our specialty is faced with enormous challenges. At the same time, however, we have an extraordinary opportunity to improve the quality of the lives of our patients and of our own lives as well. To accomplish our objectives, we must meet the challenges head on.
To resolve the five paradoxes that I have enumerated, we must strive to improve the quality and reduce the cost of cardiothoracic surgical training and to improve the quality of postgraduate education. We must remain positive role models and committed mentors for our younger colleagues. Attainment of these three objectives is critical to the survival of our specialty. It will likely require a higher level of commitment to teaching and to training than has existed in the recent past.
We must critically evaluate new technology and support its rational use. We must remain strong advocates of the patient and the patient-physician relationship, maintain our professionalism, and lead the battle to obtain affordable health care for all Americans. Finally, we must support the important initiatives of our Society with volunteerism and with dollars.
I will close with a quote from George Bernard Shaw, the distinguished playwright and novelist [20].
"This is the true joy in life, the being used for a purpose recognized by yourself as a mighty one; the being a force of nature instead of a feverish, selfish little clod of ailments and grievances complaining that the world will not devote itself to making you happy."
We are practitioners of one of the most exciting, challenging, and rewarding specialties in all of medicine. We have much to be grateful for and much to accomplish.
Acknowledgments
I am indebted to Suzan Murphy, Glennis Lundberg, Michael Thompson, Robert Wilbur, Dr Fred Crawford, Jr, and Starr Kouchoukos for their assistance in the preparation of this manuscript.
References
This article has been cited by other articles:
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  R. Friedl, H. Hoppler, K. Ecard, W. Scholz, A. Hannekum, W. Oechsner, and S. Stracke Comparative Evaluation of Multimedia Driven, Interactive, and Case-Based Teaching in Heart Surgery Ann. Thorac. Surg., November 1, 2006; 82(5): 1790 - 1795. [Abstract] [Full Text] [PDF]
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R. Friedl, H. Hoppler, K. Ecard, W. Scholz, A. Hannekum, W. Ochsner, and S. Stracke Multimedia-driven teaching significantly improves students' performance when compared with a print medium. Ann. Thorac. Surg., May 1, 2006; 81(5): 1760 - 1766. [Abstract] [Full Text] [PDF]
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R. J. F. Baskett, K. J. Buth, J.-F. Legare, A. Hassan, C. H. Friesen, G. M. Hirsch, D. B. Ross, and J. A. Sullivan Is it safe to train residents to perform cardiac surgery? Ann. Thorac. Surg., October 1, 2002; 74(4): 1043 - 1049. [Abstract] [Full Text] [PDF]
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