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Ann Thorac Surg 2007;83:361-369
© 2007 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
* Address correspondence to Dr Levitsky, Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, LMOB 2A, 110 Francis St, Boston, MA 02215 (Email: slevitsk{at}caregroup.harvard.edu).
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Introduction |
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 Top Introduction Medical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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With our present concerns about attracting residents into our specialty, it is important to look back into our own careers to determine who were the role models that helped us along the way. In 1956 (3 years after the first open heart operation by Dr John Gibbon), when I was a freshmen medical student at the Albert Einstein College of Medicine, I responded to an advertisement by Dr Charles Ripstein, an early closed heart surgery adapter, and Dr Robert Goetz, a cardiac physiologist, who were looking for a student to build a heart-lung machine and initiate a research laboratory program to obtain surviving animals after cardiopulmonary bypass.
This experience changed my focus from psychiatry to surgery and led to a senior student, surgical elective at Johns Hopkins, where fortunately for me, Dr Alfred E. Blalock assigned me to a young assistant professor, Dr David C. Sabiston, who has remained a mentor and adviser during my entire career (Fig 1). I was fortunate to obtain general surgical, cardiovascular, and general thoracic surgical residency training at the Yale-New Haven Medical Center under the influence of Drs William W.L. Glenn, the developer of the Glenn shunt, and Gustaf E. Lindskog, a pulmonary surgery pioneer (Fig 2). After military service, I joined the Clinic of Surgery at the National Institutes of Health (NIH) under Dr Andrew G. Morrow, where I learned to become a serious surgical investigator (Fig 3). I then served as a young Chief of Cardiothoracic Surgery under Dr Lloyd M. Nyhus (Fig 4) at the University of Illinois Medical Center. During the 19 years of our association, Lloyd taught me not only how to motivate and teach young surgical residents but also how to build an academic Division of Cardiothoracic Surgery. It is fitting, at this point, that I thank the more than 60 cardiothoracic surgical residents and clinical fellows that I have trained, as well as the numerous research fellows who have rotated in my laboratory. I am certain that they taught me more than I taught them.
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The theme for my talk this morning is taken from the Pulitzer Prize winning New York Times journalist, Tom Friedman’s, book The World is Flat: A Brief History of the Twenty-first Century [1]. Now, how does this book on globalization of multinational corporations, which has shrunk the world and flattened the playing field and has forced us to collaborate and compete globally, affect our world of cardiothoracic surgery? I submit that the pressures Friedman describes are part of the explanation for the fundamental changes that are underway in our profession, which we must confront if the next 50 years of cardiothoracic surgery are to see the same dynamic success and innovation in patient care as the first 50 years.
A significant factor in that equation is the ever-rising cost of health care in the United States (US), which is approaching 16% of our gross domestic product. Translated into simple terms, this means that the automobile industry pays more for the health care–related costs of workers manufacturing a car than the cost of steel used to build the car. The rising cost of health care associated with legacy pension costs for retired workers and its adverse effects on our major corporations is not a topic that we can solve this morning. It is, nevertheless, "the elephant in the tent" as we look at the globalization of cardiothoracic surgery.
Also unaddressed is the alleged 30% of total health care costs attributed to administrative fees associated with third-party payers and an additional alleged 30% of costs owing to defensive medicine and unnecessary, non-evidenced-based health care. Moreover, we continue to face an increasing burden of more than 46.6 million Americans (2005) who have no health insurance and frequently appear at our hospital emergency departments requiring urgent cardiothoracic surgical intervention, which is rarely compensated.
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Medical Tourism |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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Outsourcing jobs and services for American physicians is not something cardiothoracic surgeons have ever thought about. Historically, wealthy patients from second and third world countries have traveled to the major medical centers and clinics in the United States and Europe for expert cardiothoracic surgical care in association with the most advanced and latest technology. However, a more recent trend is a phenomenon called medical tourism, where patients from first world countries are traveling to less-developed countries for advanced medical care. In India, medical tourism is growing at 30% per year, with annual revenue predicted to be $1.1 to $2.3 billion by 2012 [2]. In Thailand, Bumrungrad Hospital treats 350,000 foreign patients per year, with volume predicted to grow at 23% annually [personal communication, M Horowitz, Nov 2005]. Medical care costs in India and Thailand are 10% to 15% of United States costs, strangely similar to the cost of manufacturing textiles in China.
For Canadian patients in a single-payer system with long waiting lists and restrictions on high-cost private hospitals, medical tourism is a rational alternative. Similarly, medical tourism also makes sense for British patients, who face prolonged waiting lists using the National Health Service and very high cost private hospitals. The cost for percutaneous coronary angioplasty and coronary artery bypass grafting in Thailand is about 50% of the cost for private care in Britain [3].
Cost is the major driver for middle class patients in the United States without health insurance associated with downsizing. A 2004 article in The Washington Post [4] documents the cost differential for elective aortic valve replacement for a patient in Durham, North Carolina. The estimated costs at Durham Regional Hospital, not including the surgeon’s fees, was $50,000 to $100,000 and required a $50,000 deposit. The total costs at the Escorts Heart Institute and Research Centre in India was $10,000, and this included round-trip airfare and a side trip during recovery to the Taj Mahal. The patient was operated on by a US trained surgeon formerly on the faculty at a major US university medical center. Another example of the reality of the new flat world.
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Corporatization of Health Care |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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Academic medical centers have not escaped from this process of corporatization. Having survived two failed hospital mergers in the 1990s, I witnessed the disruption in clinical care as well as injury to teaching and research programs resulting from anticipated economic and clinical synergies that inevitably failed to appear. Perhaps, Churchill [1] was correct when he stated "To build may have to be the slow laborious tasks of years; to destroy can be the thoughtless act of a single day," in warning us how easy it is to destroy a fragile academic medical center. Nevertheless, to survive, academic medical centers have had to adapt to corporate behavior patterns, both to keep their doors open and to maintain profit margins to sustain some semblance of teaching and academic research programs. The mantra "No Margin, No Mission" continues to echo at every academic medical center administrative meeting that I attend.
Corporatization and the need for adaptive adjustment for financial survival has forced many academic medical centers to move their original mission from teaching, research, and clinical care to becoming outstanding, profitable, clinical care providers, using clinical research as a profit-center. It is rare that the institutional review board that I sit on reviews a hypothesis-driven study rather than the overflowing plate of proposals for commercial drug and device testing, all with overhead payments that contribute to the hospital’s bottom line. With behavior similar to other commercial corporations, community hospitals and academic medical centers increasingly use their profits to invest in income-generating, ambulatory health care centers, shopping malls, and drug and device companies, the latter sometimes creating conflicts of interest when clinical trials are to be performed.
Corporatization and globalization have also forced us to abandon old ways of choosing leaders. This construct (Fig 5) by Dr Wiley Souba [6], which I have modified for our specialty, represents the past and the theoretic present corporate criteria for choosing a chief of cardiothoracic surgery. In the past, search committees looked for national stature, recruitment from a prominent institution, clinical competency, a research track record, and so on. At present, after paying lip service to the work of the search committee, the chief executive officer (CEO) of an academic medical center or a major community hospital may look for a candidate who has an understanding of the business of medicine, and I have added, first and foremost, is a master clinical surgeon with a potentially large referral base.
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We now see evidence of both realpolitik and corporatization. With costs rising faster than government support and charitable donations, since 1990, both community and academic medical centers have developed alternative sources of income with clinical activity income (Fig 6) from physician practice plans expanding logarithmically [7]. After neurosurgery and transplantation, both general thoracic and cardiac surgical procedures [8] are top contributors to hospital profit margins (Fig 7). For a variety of reasons, Medicare Part A and commercial insurance companies have historically been lavish in compensating hospitals, but not surgeons, for cardiothoracic procedures. A recent attempt to change this paradigm resulted in an outpouring of lobbyist activity in Congress from the medical-industrial complex.
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Corporatization has had additional downsides. The length of time that a cardiothoracic surgeon remains as chief of a division appears to diminish on an annual basis (Fig 8). Using the corporate model of setting productivity and financial profit margins as milestones in assessing leadership, many cardiothoracic chiefs have lost their jobs because they failed to increase volume and market share. Outstanding surgical quality, superior teaching programs, and basic and clinical research are often put aside as markers of success in the quest for increasing profits. In addition, rapid turnover of residency directors has had a destabilizing affect on attracting residents to our specialty.
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The advertising brochures of many centers positively compare their institutional outcomes with the Society of Thoracic Surgery (STS) Database; unsaid, is how accurate these comparisons are and if they are statistically valid. Who, if anyone, has audited the institutional data? Has there been oversight to prevent gaming reflected by managing mortality and moving bad outcomes to alternative categories? In this regard, I am pleased to report that the STS Database is in the process of being audited both to satisfy National Quality Forum requirements and to raise the bar for reporting accurate outcomes.
In keeping with corporatization and the need for marketing, video tapes of operative procedures, which in the past have only been used for educational purposes to physicians, are now being shown on commercial video broadcasts by institutions to increase market share and by device and drug companies for product placement. The bar has recently been raised or lowered, depending on your attitude and position on the professionalism totem pole, by hospitals producing live streaming video of operations and posting them on the Internet to mimic the "wow factor" of reality television. Newspaper reports indicate that these methods have been successful in increasing patient referral or discouraging patients in health maintenance organizations from having complex expensive procedures, depending on how the program is pitched.
The STS Guidelines for Ethical Relations With Communications Media specifically states that, "live broadcasts to the general public are to be avoided. The Society believes a possibility exists wherein participating surgeons might fail to follow proper medical procedures or might be distracted because of the media and, thereby, deprive the patient of the highest quality care."
Corporatization has even reached the professional and academic organizations and journals that we all cherish. Because of increasing member services and educational activities and the need for advocacy, specialty societies have been required to recruit professional staff to manage these complex affairs associated with legislative and regulatory bodies. To avoid unsustainable dues increases, industrial income is necessary to underwrite expenses associated with our annual meeting. The ethical challenge is to avoid subtle commercial influence and to maintain balance in the educational program.
With huge amounts of money at stake associated with product development, even the top-tiered medical journals, as evidenced by recent press accounts, must be diligent to avoid publishing misleading or inaccurate data. It is important that the STS and our journal, The Annals of Thoracic Surgery, consider strengthening the "Freedom of Investigation clause" as a condition for publication, mandating that cardiothoracic surgeons performing device and pharmacologic research for presentation and subsequent publication not sign "Gag Clauses in Clinical-Trial Agreements" that inhibit or prevent the publication of negative data. In addition, therapeutic turf battles between medical specialties that are associated with physicians allied with industry make balanced educational programming by major multispecialty organizations, featuring pro and con arguments, ethically difficult when these organizations are dependent on corporate income.
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Endovascular Surgery |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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Nick Kouchoukos agreed to lead a task force, which has resulted in two oversubscribed educational conferences and more on the way. The task force also drafted "Guidelines for Credentialing Practitioners to Perform Endovascular Stent Grafting of the Thoracic Aorta," which is scheduled to be published simultaneously in the two major cardiothoracic surgical journals. In addition, there will be educational courses at STS University during this meeting. The next step is to set up a series of short-term fellowships so that mid-career and senior cardiac surgeons can achieve clinical endovascular "wire" competence in this rapidly emerging field.
The next question is how do we manage the turf battles that will undoubtedly emerge? At the present time vascular surgeons, interventional cardiologists, and interventional radiologists all claim expertise in managing thoracic aortic aneurysms by endovascular technologies. In the best-case scenario, depending on the local hospital cultural and political situation, all or some of these specialties would care for these patients jointly.
The cardiothoracic surgeon brings specialized expertise in managing the increasing number of complications associated with this emerging technology and also has the judgment that comes with decades of experience and collective wisdom in operating on the diseased thoracic aorta. Most important, the cardiothoracic surgeon has the skills to differentiate which patients are most suitable for open chest procedures compared with endovascular approaches and understands that "by possessing a hammer, the entire world is not a nail."
In the interim, therefore, it is important that we rebuild our operating rooms with hybrid functions so that we have both the radiologic and ultrasonic imaging capabilities to perform endovascular surgery and also prepare for other minimally invasive and image-guided surgical procedures that will undoubtedly be commonplace in the near future. In my opinion, percutaneous valve insertion and percutaneous approaches for mitral valve reconstruction should be performed in the operating room to ensure safe management of early complications associated with these emerging technologies. Cardiac surgeons have to be in the forefront of clinical evaluation of these new technologies rather than being available on a stand-by basis to manage complications. Only by mastering this new and somewhat disruptive technology will we remain players in this important emerging field and ensure safe outcomes for the patients entrusted in our care.
It is also important that the STS, in partnership with the American Association for Thoracic Surgery, continues to work to provide up-to-date guidelines that clearly document recent clinical outcomes and to address complications associated with operative procedures. Some physician opinion-leader advocates who are not cardiothoracic surgeons have used surgical data that are decades old rather than recent data for comparison to champion endovascular approaches for most patients requiring thoracic aortic intervention. Obviously, in the best interests of our patients, a level playing field is necessary, which can only be obtained by objective evidenced-based data.
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Resident Training |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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The American Board of Thoracic Surgery has begun to address this problem by making certification by the American Board of Surgery optional rather than mandatory. The board is also considering raising the bar on resident-required operative case volume, devising new tracks for general thoracic and congenital heart surgery, and suggesting that residency directors plan endovascular surgery programs. However, because the cardiothoracic world is becoming flat, we must accelerate adoption of these new programs.
We can also restructure our thoracic surgical residencies to further decrease the amount of time required in preliminary general surgical programs. We can eliminate weak, low-volume training programs with unstable academic leadership and decrease noneducational activities disguised as clinical educational activity. We can foster educational innovation through e-learning and other new technologies. Most important, we can find ways to accommodate the women who want to have children during the course of their residencies.
Finally, all residency directors have an obligation to actively assist their graduating residents in finding an appropriate job. In this regard, this STS meeting will have its first structured job fair. The STS has solicited information on open job positions and advanced clinical fellowships and arranged a private office for confidential on-site interviews to accelerate this process.
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Proposed Solutions |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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On a personal basis, I love and respect my general surgical colleagues, but conferences and grand rounds on cardiomyopathies and heart failure are much more interesting than cancer of the pancreas and the latest twist and turns of performing a Whipple procedure. Despite this historical background of separation, wouldn’t it be more rational to have departments across organ or disease lines, such as cardiovascular disease and pulmonary disease, rather than contrasting pharmacologic and mechanical therapeutic approaches in the medicine/surgery paradigm, which assumes that surgeons have a limited diagnostic and therapeutic horizon?
In the early 1990s, there was a movement toward single product-lines, which for the most part was rapidly abandoned as chairpersons of medicine and surgery became anxious and were reluctant to give up their respective "cash-cows." The development of specialty hospitals such as heart hospitals or cardiovascular centers, within or attached to a major medical center, compensation models that focus on proceduralists as a separate entity, in contrast to patient visit–based physicians and the concept of disease-management practitioners, have already furthered this concept. Despite medical school and hospital corporate vested interests, physician-entrepreneurs will continue to develop new models of care that will improve efficiency and outcomes.
If we are to join other disciplines in organ-based departments, it is important that we redefine ourselves. As an example, the Accreditation Council for Graduate Medical Education defines neurologic surgery as a discipline of medicine and that specialty of surgery which provides operative and nonoperative management (ie, prevention, diagnosis, evaluation, treatment, critical care, and rehabilitation) of disorders of the central, peripheral, and autonomic nervous systems. On the other hand, thoracic surgery is very narrowly defined as encompassing the operative, perioperative, and critical care of patients with pathologic conditions of the chest with a major focus on the operative or technical procedure. All the accumulated knowledge and experience devoted to preoperative surgical decision making as well as diagnostic workup of the patient for surgical suitability or alternative therapies appears to be missing.
A few minutes ago I stated that endovascular surgery of the heart, great vessels, and aorta should be performed by thoracic surgeons as the disease manager, because we have the special skills, knowledge, and judgment to provide the full array of both open and endovascular procedures. It is imperative that we redefine ourselves and accurately describe what we do and also be certain that our thoracic surgery residency programs provide an educational curriculum that encompasses all the elements of operative and nonoperative management of cardiothoracic disease. If thoracic surgeons give up disease management, we will wind up as narrow proceduralists and others will assume leadership roles in driving the new flat world of cardiothoracic surgery.
I realize that developing cardiovascular and pulmonary disease departments will not occur overnight and is a long-term strategic plan. Perhaps the first tactical step to consider is the reunification of cardiothoracic and vascular surgery. Many of the more senior members of the STS were formally trained in both cardiovascular and general thoracic surgery. In the precoronary surgery era, 40% to 60% of cases performed by a cardiovascular surgeon were vascular surgery cases. With the assistance of Dr Gerald Rainer, the Society Historian, I was able to obtain the original STS logo adopted in January 1965 (Fig 12). The peripheral vascular portion of the STS logo, exemplified by the abdominal aortic aneurysm, was changed in 1994 to the thoracic aorta as cardiac surgeons turned away from peripheral vascular surgery and focused their attention on coronary artery surgery. Fortunately, the American Board of Thoracic Surgery application has continued to document "major peripheral vascular surgery" as part of the "Major Cardiovascular Procedures Section." Both specialties and our patients would benefit, if reunification occurred.
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Professionalism |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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This the last time I will formally address you as president of this Society. I would like to encourage a new generation of women and men to climb the ladder of leadership. They should be reminded that the concept of professionalism, which even in these days of corporatization of health care and the flat world is still the very basis of the founding of organizations such as the STS, should be part of our thinking in all of our clinical activities. It is the foundation of our social contract with society in return for the exceptional privileges granted to us by society. I have always felt personally honored with patients’ and societys’ trust in allowing me to hold their hearts and lungs and their very lives in my hands on a daily basis. There are numerous definitions of professionalism; the ones that I like best have been articulated by Kenneth Ludmerer [10] of Washington University and Miles Shore [11] of Harvard Medical School, which include:
It is only by adhering to these verities, will cardiothoracic surgery remain a profession while managing this "new flat world of medicine." I am certain that cardiothoracic surgery will change, and grow and thrive, as long as we persist and maintain our capacity to adapt and innovate.
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Footnotes |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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References |
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TopIntroductionMedical TourismCorporatization of Health CareEndovascular SurgeryResident TrainingProposed SolutionsProfessionalismFootnotesReferences |
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