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Ann Thorac Surg 2001;71:757
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, University of Tennessee Center for the Health Sciences, 1325 Eastmoreland Ste 310, Memphis, TN 38104, USA
e-mail: fhcole{at}utmem.ed
To the Editor
With regard to the article by Gilbert and colleagues [1] and the accompanying editorial by Naunheim [2], we would like to make the case for including the follow-up clinic in the surgeon’s care of the bronchogenic carcinoma patient. In a detailed study from M.D. Anderson, Walsh and colleagues [3] could show no survival benefit, so perhaps the question of "whether" to follow is as pertinent as "who" should provide this service. We would submit that follow-up visits potentially benefit both the patient and the surgeon.
Regarding the benefits to the patient, regular visits including only vital signs, weight, interim history, physical examination, and a chest roentgenogram are a relatively inexpensive means of reassurance to the patient and also serve to strengthen the rapport developed by a joint effort against a life-threatening illness. As the vast majority of recurrences will be systemic and not local we concur with Dr Naunheim that the likelihood of a surgeon discovering a newly resectable lesion is not great; on the other hand the ordering of appropriate scans to evaluate symptoms suggesting distal spread is also well within the province of a knowledgeable thoracic surgeon. With the current emphasis on "team therapy" the thoracic surgeon is called on to be knowledgeable about other treatment modalities, and this aspect of modern medical practice may make more follow-up clinic demands on us, rather than less.
So far as benefits to the surgeon are concerned we believe that following a significant number of patients over a period of many years contributes to one’s overall understanding of the disease process. In addition the availability of a reservoir of "cured" patients is extremely valuable for daily resident teaching and conference presentations; discussion of such patients can discourage the tendency toward nihilism that sometimes accompanies the diagnosis of lung cancer. We would certainly agree with Dr Naunheim that there is a positive effect on one’s ego in seeing a patient doing well, but this is balanced by the early cerebral metastatic lesion in the young businessman whose sleeve resection went so perfectly. In a world in which we must obtain permission from a clerk to perform a needed procedure and then fight with the utilization review personnel to allow our patient hospital time to recover, we shall not apologize for enjoying an occasional positive reinforcement!
We do not violently disagree with either author, but simply would make the case that the thoracic surgeon is quite able to follow these patients if such activities can be included in one’s schedule. Perhaps Dr Naunheim makes the most compelling argument for such follow-up: " ... few of us wish to become merely surgical technicians residing in the operating theatre." A good surgeon must first and always be a good physician.
References
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