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Ann Thorac Surg 2001;71:1399
© 2001 The Society of Thoracic Surgeons
a Department of Cardiovascular and Thoracic Surgery, National Heart Institute, 49, Community Center, East of Kailash, New Delhi 110 065, India
e-mail: padmavat{at}del2.vsnl.net.in
To the Editor
I read with interest the article by Drs Early and Roberts in the January 2000 issue of The Annals of Thoracic Surgery [1]. Through this article, they have highlighted certain concepts in cardiac care which have an important bearing on the total outcome or ultimate results of the unit. As pointed out by them, numbers do reflect a busy practice but not necessarily the results, and it is possible to get good results in a smaller practice. This article is perhaps an important lesson for the cardiac surgical resident and the young surgeon, as it points out those essential components of a cardiac surgical program that make it successful.
Again quoting the STS Ad Hoc Committee on Physician Specific Mortality Rates for Cardiac Surgery, "Not uncommonly, poor outcomes were found to be associated with problems in the overall system rather than with individual surgeons" [2], the background of a successful cardiac surgical program is the "system." Especially in "high volume" centers, a "watertight system" provides the backbone. But what works in the foreground, constantly, is the approach, attitude, and personality of the operating surgeon. A surgeon with a very incisive, shrewd, "no-nonsense" and noncompromising attitude towards maintenance of standards of care will always make sure that the window of opportunity is utilized in case of trouble, and "smoke" is taken care of before it becomes "fire." (As mentioned in the authors’ report, a crude mortality rate of 0.33% in an unselected case mix is a result any surgeon will envy.) This attitude tends to trickle down the hierarchy of caregivers of that particular unit. Thirdly, if along with the "system" and "attitude," interpersonal relationship is promoted in the unit, the result can be astounding. In my opinion, with above factors operating, the volume of cases becomes less meaningful. Numbers are necessary to keep the system "well-oiled" and prevent "disuse atrophy," but probably the lower limit is still not defined.
Doctors Early and Roberts also mention "great deal of personal effort and our time investment per case." This is basically an indicator of continuity of care. If a patient is cared for by the operating surgeon (whose motivation and interest in patient’s well-being is maximum, as compared to other members of the team) from admission till discharge, continuity is maintained in the care provided, and new problems can be easily compared or seen in the perspective of previous problems or the condition of the patient.
Lastly, it is my sincere feeling that if I have to undergo cardiac surgery, I will choose a center like that of Drs Early and Roberts. Probably, I shall be "the patient" and not "just a patient" in that center.
References
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