Ann Thorac Surg 2002;74:3-12
© 2002 The Society of Thoracic Surgeons
Presidential address
Unity and participation: embracing counterintuitive survival skills
Mark B. Orringer, MD*a
a University of Michigan Medical Center, Ann Arbor, Michigan, USA
* Address reprint requests to Dr Orringer, General Thoracic Surgery, University of Michigan Medical Center, 1500 E. Medical Center Drive, 2120 Taubman Center, Box 0344, Ann Arbor, MI 48109, USA
e-mail: morrin{at}umich.edu
Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
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Introduction
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The insight one gains at the helm of this dynamic organization is enormous. The Society of Thoracic Surgeons has been aptly characterized "the face of our specialty" in this country and throughout the world. The topic of this address reflects what I believe is among the most critical tasks before us: greater unity within the specialty and more active participation by each of us in the organizational, socioeconomic, and political issues facing us. Unfortunately, for a variety of reasons to which we can all relate, such unity and participation are not intuitive to cardiothoracic surgeons, and embracing these survival skills is an enormous challenge.
In recent months, we have witnessed the United States military relentlessly pursuing the Taliban and Al Qaeda in the war against terrorism. There is an analogy between the armed forces and cardiothoracic surgeons. We are the Special Forces of the medical profession; tough, hardened, dedicated, competitive—absolutely committed to winning for our patients (Fig 1).
But in the new millennium, how our traditional thoracic surgical culture has been transmitted during our long years of residency, and how we learn as residents to respond to external stresses, may not be serving us well.
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Fig 1. The modern cardiothoracic surgeon-the "Special Forces" of the surgical profession—resplendent with headlight, syringe, cardiac cannula, scalpel, sternal saw and vascular clamp: tough, hardened, dedicated, and competitive.
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After 7–9 years of residency, we have mastered the "foxhole mentality"; we have learned to dig in and keep our heads down until the "noise" overhead has passed (Fig 2).
Every rotation has its end, and harsh, unappreciative faculty are left behind; and if one can just "suck it up" and "tough it out," this too shall pass. An outstanding recent graduate of our Michigan Thoracic Surgery Residency completed his general surgery residency at one of the recognized "best" institutions in the country, where three critical rules for surviving surgery residency were emblazoned on his heart: (1) always work harder; (2) trust absolutely no one (and as a corollary to this, suspect sabotage); and (3) try not to act like an idiot even if you are one.
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Fig 2. The modern cardiothoracic surgeon—master of the "foxhole mentality"—immersed in professional "busyness" and keeping his head down as major issues that need to be addressed explode overhead.
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Humorous, isn’t it? Not to those of us who, as surgical educators, are watching the erosion in the number of US medical school graduates entering the surgical disciplines. We are "hammered" for 5–7 years in general surgery residency, gradually ascending to the chief residency year, only to be flattened again by thoracic surgery residency. Our residencies have been largely punitive "boot camps" (Fig 3).
And when we emerge, we know how to provide unparalleled one-on-one doctor-to-patient care, uncomplaining, mouths shut, oblivious to the toll on us. Years of "yes sir," "no sir," "don’t make waves," have produced generally introverted, extraordinarily self-reliant, heads down kinds of guys and gals. And, friends, it is hard to see the horizon when one’s gaze is focused on one’s feet! Against this backdrop of who we are, let’s examine some of the critical issues before us today.
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Fig 3. The punitive "boot camp" environment of our residencies tends to create "heads-down guys and gals" who are introverted, self-reliant, and do not "make waves."
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The computer age—electronic communication and database participation
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"Computer challenged" until 4 years ago, I now rely on the computer as an invaluable communication tool. With the breadth of current STS activities—member and patient education, clinical data collection and reporting, patient advocacy, health policy, and government relations—the key to the ability of the STS to represent its members and to be responsive to your needs is good communication. Each of us should have an e-mail address through which our headquarters can reach us—for rapid surveys, to respond to a Washington inquiry, a committee announcement, or a specific question to you, and through which you can communicate with STS leadership. With the support of our headquarters IT staff, we can now communicate on the same software platform on the Internet. Under the leadership of Dr Jeff Gold, our Web Editor, the robust STS web page now provides you with timely information about your specialty. I urge that you not use your office computer just as a means for your nurse to transmit data to referring physicians, deleting e-mails you may be receiving from the STS before you ever see them. You cannot participate if you are not informed.
The STS National Database is another key area for specialty-wide participation. Now, with more than 1.8 million patients entered, our Cardiac Database is the largest in the world, a recognized gold standard. But only 32% of our members participate. The rest are "too busy," unable to afford the cost or time for data tracking and recording; it’s something for someone else to do. The other two subspecialty components of thoracic surgery have now also responded to the database mandate. With Dr Gus Mavroudis’ energetic leadership, the Pediatric Cardiac Surgery Database is now functioning. The STS General Thoracic Surgery Database will be online within the next few months. And I speak from personal experience that these data have a direct impact upon our reimbursement.
Last year President Jack Matloff parachuted me into the 2000–2001 deliberations of the Relative Value Unit Committee (RUC), a group of physicians representing all the medical and surgical specialties, which evaluates specialty requests for proposed fee increases and then makes its recommendations to Center for Medicine & Medicaid Services (formerly Health Care Financing Administration [HCFA]). And in our budget-neutral system, in which a gain for one specialty means a loss for another, data drive these decisions and win or lose arguments at the RUC.
Our STS representatives, armed with credible "compelling evidence" from our 1.5 million patient National Database, recommended increasing cardiac surgery fees, since our patients are sicker (with more comorbidities) and older, but their operative morbidity and mortality have remained constant or improved since the last 5-year review. And then came the STS request for substantial increased reimbursement for pulmonary and esophageal resections and other general thoracic operations, which had not been revalued for well beyond 5 years. And in the absence of general thoracic outcomes data to substantiate our position, our initial recommendations to the RUC were denied. But Dr Sid Levitsky, our STS RUC representative, strongly protested, and we were given a chance within several weeks to represent our case for general thoracic surgery. We needed data. And, in true thoracic surgery fighting spirit, my colleagues and friends at 10 academic general thoracic surgery programs across the nation, each with his own homegrown database, responded to my personal request for information and help. The personal expenditure of time and energy collecting and analyzing data on more than 8,000 patients going back to 1985 was enormous. But the STS returned to the table with convincing hard data showing that our patients are older and sicker—eg, after preoperative chemoradiation therapy—compared with the 1985 original RVU reimbursement population. These data "won the day" for the entire specialty at the RUC that day. But the RUC made it clear that it wants data representing "the typical patient," and those undergoing surgery at academic centers are not necessarily typical of national norms. In the future, outcomes data from a few academic centers will not suffice. Success at the RUC will require a strong, representative National Database.
Another key database front is patient advocacy. Since the 1999 Institute of Medicine Report of between 45,000 and 98,000 annual deaths in the US as a result of medical errors [1], demands upon the profession for greater quality in patient care have intensified. And the assessment of quality begins with data. Our National Database places us well ahead of other specialties in this regard, demonstrating to the public our commitment to the improvement of patient care delivery. The database now provides a mechanism for national clinical trials for identifying optimal methods of patient care and new technology, such as our transmyocardial revascularization study funded by the Agency for Health Care Research and Quality. Each of us, regardless of our type of practice, needs to participate in the National Database. It is surely preferable to have our risk-adjusted norms of morbidity and mortality for cardiothoracic surgery become accepted standards and determinants of "quality" rather than an arbitrarily imposed annual number of operations as a surrogate for quality.
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Educational issues
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No modern Thoracic Surgical Presidential Address would be complete without lamenting the loss in our residencies of "the brightest and the best," and then, of course, parroting the solution that has become the "guiding light"—drop the requirement for American Board of Surgery certification and shorten the length of general surgery residency from 7 to 8 years to 6 to 7 years. Our training will then be more attractive to young physicians, who will flock to our residencies, and everything will be just fine. This is a nonsequitur and wishful thinking. Since 1997, the number of US medical school graduates applying to our thoracic surgery residencies has been gradually declining and is less than the 140 or so available positions (Fig 4).
In the early 1990s, approximately 160 US medical school graduates applied for our 140 positions; 70% "matched," and roughly 30% were rejected (Table 1).
At the same time, 25 or so alien foreign medical school graduates applied to our programs; about 40% were matched, and 60% were rejected. (The term "alien" foreign medical school graduate distinguishes this group from US students who graduate from foreign medical schools.) At present, the number of US medical school graduates applying for our 140 positions has fallen to 112, nearly 90% are matched, and less than 10% rejected. Of the alien foreign medical school graduates applying, about 90% are now accepted, and 10% are rejected. But do these data make the case that we are losing the brightest and the best of the applicants, or do they emphasize that there are just fewer applicants out there? The profile of our residents is changing.
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Fig 4. United States medical school applicants to thoracic surgery residency programs and positions filled through the Match. Since 1997, there have been fewer US medical school graduates applying for thoracic surgery residency than the approximately 140 positions available.
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In 1992, in a sentinel effort to profile the contemporary thoracic surgery resident, Dr Ben Wilcox and his Committee on Graduate Education in Thoracic Surgery surveyed the 140 thoracic residents graduating in June 1993 [2]. Their general surgery operating experience was obtained from the American Board of Surgery and analyzed. The American Association of Medical Colleges surveys all graduating senior medical students annually and, among other things, asks about potential career interest in a specialty. Wilcox noted that in 1990, 72 of the graduating seniors (about 0.6%) indicated an interest in a thoracic surgical career. In the past 5 years, however, those expressing an interest in thoracic surgery have declined further to a stable 40, to 0.3% of the 16,000 graduating each year (Fig 5).
We are not getting to the young people either before or in medical school and stimulating their interest in surgery in general and thoracic surgery in particular. Length of training is not an issue in career selection when students do not even know what the field is or have not had contact with thoracic surgery role models.
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Fig 5. Graduating medical students expressing interest in thoracic surgery careers. American Association of Medical Colleges Survey results (Salazar J, Laudito A, 2001 Thoracic Surgery Resident Association, unpublished data).
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The 1993 graduates performed approximately 1,200 operations each during general surgery residency, with an average of 360 major operations as a chief resident. Those who advocate an "integrated" surgery/thoracic surgery residency, eliminating the general surgery chief residency year, should not forget that our residents now come to us as experienced surgeons performing nearly one major operation a day for the year before thoracic surgery residency. Ask our Canadian cardiothoracic colleagues about their separate cardiac and thoracic surgery "integrated" residents with a much-abbreviated general surgery experience. Their frustration at needing to teach "knot tying 101" to their much "greener" residents is often expressed.
Wilcox obtained responses from 112 (80%) of the 140 graduating 1993 residents surveyed. This year I sent a variation of the Wilcox survey to the 126 general surgery residents listed by the National Thoracic Surgery Residency Matching Program as being matched into thoracic residency programs beginning in July, 2002; and after some gentle urging, responses were obtained from 121 (96%). We can now compare the profiles of the Class of 1993 and the incoming Class of 2002 (Table 2).
The average age of the 1993 graduating thoracic surgery residents was 34 years, and that of the incoming class of 2002, 33 years; they will finish thoracic surgery residency, as a whole, 1 or 2 years older. But further analysis (see below) indicates that we must now be careful when generalizing about our residents as a whole, because they are no longer homogeneous. Thoracic surgery remains a male-dominated specialty, but there is hope—9% of the incoming residents are women versus 6% of the graduating class of 1993. White dominance of our specialty is diminishing—59% now versus 90% in 1993. The proportion of African American residents remains stable at around 5%, but there are 3
times more Hispanic residents (7% vs 2%). The most striking demographic change is a sixfold increase in Asian-Pacific residents—from 4.5% in 1993% to 27% of the total now. As a residency program director, I have seen Asian-Americans establish themselves among the brightest and best of candidates applying to our University of Michigan program, with top schools, grades, honors, and general surgery residencies. Why is this? A number of my Asian-American residents tell me that they are among the first American-educated generation in their families, their parents having come to this country (often with very limited resources), labored so that their children could have all the advantages of the American educational system, and passed on a dream of stature and respect as a doctor—a cardiothoracic surgeon. They have been taught at home that hard work is an expectation of life that brings with it rewards of success and happiness. Curious, I asked on the survey that I sent the following: "It has been suggested that many of our residents bring with them a work ethic instilled by parents from other countries. Were both of your parents born in a country other than the United States?" Yes or no? What is your guess—20%? 30%? Actually, 51% of the incoming 2002 residents are offspring of parents from foreign lands. Our demographics are clearly changing!
How do the current residents compare with the "brightest and best" of the Wilcox 1993 survey (Table 3)?
More medical students are "unranked" now, but 71% of the 2002 incoming class (vs 79% of the class of 1993) still graduated within the upper third of their class. The number of Alpha Omega Alpha (AOA) Honor Medical Society members has decreased from 38% to 27%, in part because one quarter of the incoming class attended foreign medical schools (see below) where there is no AOA. Similar numbers were in undergraduate honor societies and had at least 6 months of research as students. Disturbingly, only 55% (vs 70% in 1993) have had at least a 2-week thoracic surgery clinical rotation in medical school. Nearly three times more (23% vs 8%) of our incoming residents are foreign medical school graduates, and this must now be carefully considered when generalizing about our residents. For example, for the 1993 graduates, the average time between graduation from medical school and the completion of residency was 8.6 years (Fig 6).
The average time from medical school graduation to the start of thoracic surgery residency for the incoming 2002 class is already 7.5 years. One might conclude from this information that, by the end of a 2- or 3-year thoracic residency, most of the incoming residents will have invested 9 to 10 years after medical school, longer than the Class of 1993. But further analysis shows the impact of foreign medical school graduates on the overall group statistics. The foreign medical school graduate have been out of medical school longer, likely having started a residency in their country and then started over again in a US residency. The US medical school graduates will complete residency in the same number of years as the Class of 1993. About 10% fewer of the incoming class obtained their general surgery residency training at university hospitals, most of the difference being made up at community hospitals and private clinics (Table 4).
When did the incoming class decide on a career in thoracic surgery? The statistics are remarkably similar: about half decided before or in medical school, and half during general surgery residency after exposure to cardiothoracic surgery rotations (Table 5).
If we require our future residents to make their career choice in medical school and to match directly into cardiothoracic residencies, this latter half will be lost to the specialty. The top three factors influencing our residents’ choice of a career remain constant: role models, the intellectual content of the specialty, and exposure to the specialty through rotations in general surgery residency (Table 6).
Encouragement from faculty, disappointingly, remains near the bottom of the list. And again, the expectation of financial reward is apparently not motivating our residents.
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Fig 6. Thoracic surgery resident profile showing years after medical school for the 1993 graduating class (1993 graduates) reported by Wilcox and colleagues (2) and the 2002 incoming class, and the difference between United States and foreign medical school graduates in the 2002 incoming class. (avg = average; Grads = graduates; Med = medical; U.S. = United States; Yrs = years.)
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The declining number of US medical school graduates applying to our residencies has created angst within the specialty. Despite the 1992 advise of Wilcox and colleagues to improve the quality of our resident education process and not focus on the length of residency per se, time and energy have again been expended on the age-old debate as to whether the requirement for American Board of Surgery certification should be eliminated and our residency shortened by 1 year. But are we attracting fewer US medical school graduates because of the length of our residency, or are other factors at play? Are we attracting fewer resident applicants because half the graduating medical students are women, and our male-dominated specialty has not adequately addressed this issue? Is it significant that 71% of our residents have spouses waiting at home or that 43% have children, as some variation of the incredibly long hours and relatively brutal call schedule that my generation endured still survives? Is it significant that 30% of the incoming class of 2002 finished medical school with an educational debt between $51,000 and $100,000 and, for 20%, more than $100,000? (Table 7).
Could it be that our lifestyle is not particularly attractive to most of the younger generation, or that the frustration over our hard work in the face of declining reimbursement is having its effect, or that our job market is simply now saturated? Dismantling our residency system will not address any of these issues.
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Table 7. 2002 Incoming Thoracic Surgery Resident Profile (n = 121)—Marital Status and Educational Debt After Medical School
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In our usual "hunker down" thoracic surgery posture, we have viewed the decline in applicants from US medical schools within the very narrow confines of our specialty rather than in the context of national trends in undergraduate and graduate medical education. Since 1980, concern about a possible physician surplus has constrained the growth of allopathic US medical schools, which consistently graduate approximately 16,000 students each year [3].
The trends in graduate medical education, however, have been quite different. From 1980 to 1993, the number of all residents in US allopathic programs rapidly expanded and leveled off at just below 100,000, driven primarily by staffing needs of hospitals, availability of residents, and Medicare funding of graduate medical education. There are approximately 22,000 first-year residents with no previous experience in a residency program (Fig 7).
In other words, there are 30% more resident positions than the 16,000 medical students graduating each year. Who fills the gap? Foreign medical school graduates now constitute 25% of all residents in this country, and osteopathic medical school graduates 3% to 4% (Fig 8).
Each year, approximately 5,000 foreign medical school graduates are hired by US hospitals to fill their residency positions for which there are not enough US medical school graduates. And these foreign medical school graduates finishing ACGME-approved general surgery residencies are eligible to apply to our thoracic surgery programs. Remarkably, this is occurring at a time when applicants to US medical schools are being turned away in substantial numbers (Table 8).
Between 1980 and 1999, the ratio of medical school applicants to those accepted varied from 2.1 to 2.7. In 1999, just over half of all medical school applicants were rejected. And this is not because they are poor candidates; the mean grade point average of all applicants has steadily increased (it was 3.43 in 1999).
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Fig 7. Residents in United States allopathic programs, 1993 to 1998. (Adapted from American Medical Association data presented in [3].)
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Fig 8. Residents in United States allopathic programs according to type of medical school attended. Adapted from American Medical Assocation data presented in [3].
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And while the number of graduates of allopathic US medical schools remains constant, in 18 years, the number of graduates of osteopathic medical school graduates has doubled (from 1,059 in 1980 to 2,120 in 1998), and nearly half the osteopathic med school graduates enter allopathic residency programs.
There is simply a shortfall in the supply of US medical school graduates to fill all of the available residencies in this country, and Thoracic Surgery is not immune to this. This has nothing to do with length of training or American Board of Surgery (ABS) certification. A national assessment of the justification for so many resident positions, with particular focus on service versus education needs, is overdue. A cogent argument might be made for increasing the number of US medical school graduates to parallel more closely the availability of residency positions. Perhaps this is where some of our efforts at effecting health policy in the near future should be directed rather than—out of frustration—dismantling a system of residency education that, although imperfect, has served the specialty well.
The appropriate length of residency continues to be debated. From the barber-surgeon of seventeenth-century England, to the electrician and plumber who helped build our new house, 7 years has evolved as an expected minimum time to master a body of knowledge encompassed within a profession. Many residents still value the maturation process of surgical residency and the chief resident year. When surveyed as to whether ABS certification should be required to practice thoracic surgery, 58% still respond "yes." On an issue that has generated even greater conviction, however, 89% believe that they should be able to complete the ABS certifying process in the chief year of general surgery residency so that they may spend their thoracic surgery residency studying thoracic, not general, surgery. With the recent change in leadership and philosophy of the ABS, favorable resolution of this long-frustrating issue on behalf of our residents hopefully is possible. The residents do not expect to be able to do what our specialty demands by means of a "shortcut." When asked their opinion of the appropriate total number of residency years after medical school to become a thoracic surgeon, 9% of the 2002 incoming class responded 6 years; 68.5%, 7 years; 16.5%, 8 years; and 6%, 9 years. In other words, 85% believe that 7 to 8 years of residency after medical school are appropriate to becoming a thoracic surgeon; less than 10% say fewer than 7 years.
Today’s medical students are not the same as 10 years ago. Nearly 50% are women. More are nontraditional students who are older, often with prior careers. There are more minorities. The "Generation X" applying to medical school is more focused on technology and less concerned than their Baby Boomer parents with material success and high incomes, and more with lifestyle issues—balancing their personal and professional lives. For better or for worse, we must adapt, at least in part, to our new students. Harsh, demeaning behavior directed toward residents is now socially unacceptable and, for our profession, a guarantee of extinction. We must address realistically and proactively the issue of resident work hours; the "old days" are gone! The provision of true mentorship for our residents and medical students is a mandate—showing an interest in them as human beings with personal lives and problems. There must be earlier (ie, in the first 2 years) involvement of thoracic surgery role models in medical student education and the development of innovative methods of "marketing" our field to young people. The American College of Surgeons now brings to its Annual Clinical Congress local bright minority students who are shown the exhibits and interact with surgeon guides. Doctor Gerald Rainer has led a similar effort for the STS—a program that I have encouraged him to continue and that we need to expand—serving as a guide and role model to local high school students brought to our meeting for a brief exposure to our exciting exhibits and the intellectual and technical challenges of cardiothoracic surgery. The enormous amount of work done by the Thoracic Surgery Directors Association and, particularly, Dr Jeff Gold, in implementing our thoracic surgery residency curriculum by the development of innovative hybrid CD-ROM technology bears special mention [4]. This type of activity sends a clear signal to interested medical students and surgical residents of our commitment to providing high-quality postgraduate education.
Thoracic Surgery began as an offshoot of Surgery, and we should be very cautious about breaking further from American Surgery as our educational foundation. Do not devalue the general surgical operative experience that our residents receive simply because it is not thoracic surgery. American cardiothoracic surgeons are, and always have been, surgeons first. And surgery in general, not thoracic surgery alone, is failing to attract as many US medical students to its ranks. Sixty-eight categorical general surgery residency positions did not fill through the Match last year. The number will be greater this year. The message that surgeons have been sending to medical students needs to change. In unity with American Surgery, we should be working collectively to figure out how to reverse this trend.
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Geriatrics and thoracic surgery
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Changing gears for a moment, there is a relatively new initiative to which our specialty must pay attention—namely, geriatric thoracic surgery. Our patients are older and, with the aging of the Baby Boomers, this phenomenon will increase. The US population aged 65 years and older will increase from 35 million (13% of the population) in 2000 to 78 million (20% of the population) in 2050, and those aged 85 and older will grow from 4 million to 31 million [5]. The geriatric population, like the pediatric population, has unique characteristics that influence surgical outcomes: more comorbidities and unsuspected associated serious diseases; tremendous susceptibility to iatrogenic disease; functional status limitations; a less forgiving physiology; and far greater sensitivity to anesthetic agents and analgesics, to name but a few. We and our residents must become better educated in basic geriatric principles of care, which can be generalized across all medical disciplines and from which our patients will benefit. The current 9,000 geriatricians in this country will not compensate for the projected 30,000 needed [6].
Aware of this, the John A. Hartford Foundation, partnering with the American Geriatrics Society, and the late Dr Dennis Jahnigen, a prominent geriatrician, established a grant entitled "Increasing Geriatrics Expertise in Nonprimary Care Specialties," which is basically intended to improve geriatric education of medical and surgical residents [7]. Ten non-primary care medical and surgical specialties, including thoracic surgery, are now participating. Discretionary grants to the specialties and career development awards for specialty faculty who are in academic careers emphasizing geriatric principles are being made available.
We are behind other disciplines in addressing this topic. The American Board of Surgery has added questions on geriatric surgical problems to its Surgery in-training and qualifying examinations. The Association of Program Directors in Surgery has developed a detailed surgical geriatric curriculum. The orthopedic and otolaryngology professional societies have existing Committees on Aging to deal with specific issues related to the elderly within their disciplines.
If our new proposed Bylaws being voted upon at our business meeting this afternoon are approved,1 one result will be the establishment of a Workforce on Aging with two subcommittees, the first to focus upon issues unique to elderly cardiothoracic surgical patients, and the second, on a related (but, until now, ignored) subject—the aging thoracic surgeon. After the most arduous of residencies and the next 30 to 35 years of functioning professionally at 110% of capacity, if we live to see it, we are faced with retirement, which, like other stresses in life, is a major loss [8]: (1) loss of purpose—when the enormous personal gratification of restoring sick patients to good health, teaching, and perhaps doing research is gone; (2) loss of routine—when the comfort of our predictable, compulsive orderliness and routines involved in patient care (awakening early, rounding daily, operating, maintaining current correspondence, seeing patients in the office) is gone; (3) loss of "busyness"—when we are no longer over-worked, we cannot hide behind the shield of professional "busyness," and we become vulnerable to exposure to those mundane details of everyday life that we have so masterfully avoided all of these years; and (4) loss of companionship—when the comfort of our exclusive club, in which our friends are predominately physicians, and the relaxed atmosphere of our surgeons’ lounges and hospital conference rooms are gone. And our wives may experience losses in our retirement as well: (1) loss of personal "space" —as husbands who have never been around continue their role as compulsive surgeons and try to organize the house; (2) loss of "free" time—wives who have become accustomed to being alone more than other wives are faced with rearranging their work or activity schedules to be with us; and (3) loss of leisure—as husbands who have seldom sat down for a meal are now around for three meals a day, their wives are faced with more meal preparation and cleaning up.
Our Workforce on Aging, as a service to our members, will be charged with developing more open dialogue about these and other issues of retirement. I encourage those of you contemplating or experienced with retirement to participate in the activities of the Workforce on Aging.
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Unifying thoracic surgery’s infrastructure
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I would now like to address a final topic—the infrastructure of our specialty. Last October, the STS Council voted for the organization to become self-managed, ending a nearly 30-year relationship with Smith-Bucklin Associates, our association management company. This decision was not made casually. It was the culmination of a 9-month, in-depth analysis of management services and the status of other, similar-sized medical professional societies. The STS has approximately 4,000 members and a $6 million budget. Virtually all other comparable medical professional societies are already self-managed. The business focus of the STS has been sharpened. The searches for a new executive director and a new headquarters for the STS are well underway.2 And I want to return for a moment to my theme of greater unity both inside and outside the specialty. Since the inception of our specialty, the independence and stature of Thoracic Surgery have been espoused by many among us who see no further need to be associated with General Surgery. I personally believe that such a posture is unwise and short-sighted, particularly now. One and one-half years ago, Dr Tom Russell, Executive Director of the American College of Surgeons, organized a meeting of the leadership of the surgical specialty societies to discuss our common socioeconomic and political issues. At the table with the presidents, executive directors, and government relations representatives of each of these 15 or so organizations, I was struck by our collective lack of wisdom: 15 surgical professional organizations, each expending from $200,000 to $800,000 a year on our individual lobbying efforts in Washington, and none being particularly effective in isolation. Might we not make more of an impact on Capitol Hill as part of a more unified surgical voice under the auspices of the American College of Surgeons? Might a pooled surgical PAC not have more far-reaching an effect than our individual PAC’s? Our divided self-interest groups have been our worst enemies in mounting an effective campaign against the progressive and unjustified cuts in reimbursement for our services. We need to get smart and pull our collective wagons into a circle for the greater protection of us all.
So what has this to do with STS self-management? After a rather comprehensive assessment of Chicago real estate, we are in final negotiations over our top 2 choices for our new headquarters, one of which is the American College of Surgeons building.3 With his conviction that the American College of Surgeons should be the umbrella organization for all of American surgery, Dr Tom Russell would like to see the specialty of Thoracic Surgery physically closer to the College—not as an attempt to swallow us up (as those skeptics among us will quickly surmise)—but, rather, as an opportunity for closer and mutually beneficial interaction. I support this view. And the possibility of such a relocation of our headquarters has stimulated thought about the potential benefits of further unification within our specialty. There will probably not be for many years, the alignment of stars affecting so many thoracic surgical organizations simultaneously as is occurring now. The Society of Thoracic Surgeons has made its decision to become a freestanding, self-managed organization. The Southern Thoracic Surgical Association and the Thoracic Surgery Foundation for Research and Education (TSFRE), also currently managed by Smith-Bucklin, are now reconsidering their management relationships. Both the American Association for Thoracic Surgery and the Western Thoracic Surgical Association are managed by Mr William Maloney, who will be nominally retiring this year, causing these organizations to at least rethink their management strategies as well. At the American Board of Thoracic Surgery, Ms Glennis Lundberg, the Executive Director, has retired. And the Thoracic Surgery Directors Association, sustained essentially by dues from the residency program directors, uses much of its current annual revenue to pay for its management company. If we also gently cradle the fledgling Thoracic Surgery Residents Association among our larger professional organizations, one might envision (perhaps on that floor at the American College of Surgeons building) "Thoracic Surgery Organizations, Inc," where each of our respective organizations could be headquartered, enjoying certain efficiencies and economies of scale by sharing space, equipment, and perhaps selected personnel, and benefitting from improved direct communication. Such a sharing of resources would not threaten the identity of our individual organizations, which would be maintained. But I would be remiss if I did not at least verbalize the possibility that our two largest national thoracic surgical organizations might someday become one. The historical and emotionally charged issues that led to the formation in 1964 of The Society of Thoracic Surgeons as a reaction to the "academic elite" American Association for Thoracic Surgery have all but been forgotten and are, in fact, irrelevant to most of us now struggling with the more practical issues facing our specialty. The duplicate expenditure of resources—financial and volunteer time—and division of talent and energy between our two national organizations is occurring at a time when the specialty just can no longer afford it. Paying dues to two organizations that provide national meetings with the same registration process, name badges, and postgraduate courses is inefficient. After an enormous amount of work this year, our membership will be voting today upon sweeping changes in the Bylaws of this Society that will streamline our organizational structure and change our governance (Fig 9).
There will be three Councils, reflective of the needs of the stakeholders in this organization—members, patients, and society at large—Councils on Education and Member Services, Quality Assurance and Patient Advocacy, and Health Policy and Relationships, respectively. With some imagination, one might envision a new unified "Society of Cardiothoracic Surgeons" (or whatever the name of our merged organizations would become), with a fourth Council on Academic Affairs that would accommodate all of the current functions of the American Association for Thoracic Surgery. The implications are vast. But we have a unique opportunity before us to improve the infrastructure of our entire specialty if we can think collectively and act in a more unified fashion. As is appropriate for such a far-reaching proposal, the idea must percolate through our individual national organizations. The STS is moving on, however. These are exciting times, and this Society is up to the challenge.
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Fig 9. Organizational structure of The Society of Thoracic Surgeons established by its new Bylaws adopted on January 28, 2002.
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Concluding remarks
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As I conclude, let me emphasize again my conviction that our "rugged individualism" is derived in part from repetitive punishing years of residency. Our heads down, constant focus upon one-on-one patient care creates a "busyness" that is used to justify insufficient time for personal and other professional pursuits. The survival of our specialty requires the involvement of more than a few leaders. The TSFRE struggles each year for funds to support our young thoracic surgical investigators and to send young thoracic surgeons to the Harvard course. Yet only 10% of STS members have contributed to this effort. More than 200 cardiothoracic surgeons have committed 10 days to the Harvard course at the John F. Kennedy School of Government, "Understanding the New World of Health Care," have learned how to influence health policy in Washington, and have brought back to STS membership the need to contribute to and sustain a thoracic surgery PAC. Yet only 13% of STS members have contributed. A relatively small amount of money now remains in our PAC, and a reinfusion of funds is critical. A contribution of $1,000 ($500 to the TSFRE and $500 to the PAC) from 2,000 of our members would provide vitally needed support for both the Foundation and our lobbying efforts. Most of us hate politics. But we live in an extraordinary democracy. As an ordinary citizen, but as President of the STS, I met and spoke with President Bush several months ago. Our voices can be heard in Washington.
We have learned at the Kennedy School that "all politics are local." After suffering cumulative reductions in our fees of nearly 45% in 10 years, we are now facing an additional 10% reduction through decreases both in practice expense reimbursement as well as the Medicare conversion factor. Congress has before it pending legislation to change the formula which determines the conversion factor, potentially effecting considerably the payment in 2002. And the methodology used by CMS (formerly HCFA) to determine practice expense reductions is under review by two government agencies that may support the STS position. Our ability to take advantage of these political opportunities depends upon STS members interacting with their representatives in Congress and in the Senate. At the STS booth here in the exhibit hall are banks of computers to permit onsite e-mail communication to your legislators, model letters to personalize and send on your own letterhead, and model letters that can be distributed to your patients to send to Congress. We can hunker down in our foxholes (as we all know so well how to do), or unify collectively to meet the challenge. This abuse cannot go on forever. But until we, other physicians, and our greatest allies—our patients—make it known that the status quo is unacceptable, we cannot bemoan our fate. It is up to each of us—not the other guy—to stop the damage that has been done to the specialty that we love.
Crucial to our survival, then, are unity and participation in: (1) the National Database and specialty-wide electronic communication; (2) American Surgery’s effort to change the environment of our residencies and structure a more flexible educational system; (3) mentorship and as role models to medical students and residents; (4) government relations activities, our PAC and grass roots campaign; (5) the TSFRE, an investment in our young—the specialty’s future; and (6) streamlining our infrastructure by sharing resources.
Beneath a well-known photograph of the six jets of the Navy Blue Angels traveling in formation at speeds hundreds of miles an hour only several feet apart are these words, which are àpropos today: "It is amazing what you can accomplish if you do not care who gets the credit." What we achieve together is for the future good of our specialty and the generation who will follow us. It is time to look up from our foxholes and pay attention to what is going on around us. With greater unity and participation—those survival skills that, until now, have been counterintuitive and elusive to us—we are going to win this one, too (Fig 10)!
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Fig 10. Victory of the specialty of Thoracic Surgery will follow greater unity and participation by its members in the critical issues before us.
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I thank you all for the privilege that I have had, and will always treasure, serving as President of The Society of Thoracic Surgeons.
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Footnotes
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1 The new STS Bylaws were approved by the membership later that day, January 28, 2002. 
2 Since this Address was presented, Mr Rob Wynbrandt, well known to the STS as its legal counsel for more than 15 years, has been hired as the new Executive Director/General Counsel of the organization.
3 The STS has subsequently signed a lease with the American College of Surgeons for its new headquarters to be located at the ACS building in Chicago.
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References
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- In: Kohn L., Corrigan J., Donaldson M., eds. To err is human—building a safer health system. Washington, DC: National Academy Press, 1999.
- Wilcox B.R., Stritter F.T., Anderson R.P., et al. Profile of the contemporary thoracic surgery resident. Ann Thorac Surg 1993;55:1303-1310.[Medline]
- Mullan F. The case for more U.S. medical students. Sounding Board. N Engl J Med 2000;343:213-217.[Free Full Text]
- Gold J.P., Verrier E.D., Olinger G.N., Orringer M.B. Development of a CD-Internet hybrid thoracic surgery curriculum: The Thoracic Surgery Directors Association Pre-requisite Curriculum Project. Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Ft. Lauderdale, FL, Jan 28–30. 2002.
- Statistical Abstract of the United States 1998. The National Data Book. Washington: U.S. Census Bureau, Sept. 1998:16.
- A statement of principles: toward improved care of older patients in surgical and medical specialties. J Am Geriatr Soc 2000;48:699-701.[Medline]
- Solomon D.H., Burton J.R., Lundebjerg N.E., Eisner J. The new frontier: increasing geriatrics expertise in surgical and medical specialties. J Am Geriatr Soc 2000;48:702-704.[Medline]
- Boncheck L.I., Boncheck R.M. personal communication 2001.
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R. Lee
Help wanted
Ann. Thorac. Surg.,
December 1, 2003;
76(6):
1779 - 1781.
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