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Presidential Address

The Bright Future of Cardiothoracic Surgery in the Era of Changing Health Care Delivery: An Update

University of Colorado Health Sciences Center and Denver VA Medical Center, Denver, Colorado

^_* Address correspondence to: Dr Grover, University of Colorado Health Sciences Center, Department of Surgery, C-305, Academic Office One, Bldg L15, Rm 6117, 12631 E 17th Ave, MS C305, PO Box 6511, Aurora, CO 80045 (Email: frederick.grover{at}uchsc.edu).

	Introduction

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 

I would like to first acknowledge and thank those individuals who have been so important in my life and career, making it possible for me to be selected as your president, the highest honor that I have had bestowed on me and one that I will always cherish and hope that I have fulfilled in a credible way. I would first like to acknowledge my parents, Wilma and Fred, who taught me the importance of hard work, perseverance, honesty, integrity, common sense, and a sense of humor, all coupled with a strong dose of humility. I particularly want to thank my wife, Carol, for her tremendous support, which actually began when we were both 15 and had begun dating each other as sophomores in high school. She has been with me through high school, college, medical school, and residency, and for my entire career as a cardiothoracic surgeon. As everyone knows, being married to a cardiothoracic surgeon isn’t the easiest thing because of the obligations of our profession.

I also want to acknowledge the support of our two sons, Fred Jr and Richard, who have been tremendously supportive of me and my career, understanding the time that it takes to be a conscientious cardiothoracic surgeon. I also want to thank our daughters-in-law, Theresa and Christin, for all of their support, and our grandchildren, Brooke, Keaton, and Lange, for the enjoyment they bring us.

Part of what I will emphasize today is the importance of mentorship. In the book, Advisor, Teacher, Role Model, Friend [1], it is noted that

In general, an effective mentoring relationship is characterized by mutual respect, trust, understanding, and empathy. Good mentors are able to share life experiences and wisdom, as well as technical expertise. They are good listeners, good observers, and good problem solvers. They make an effort to know, accept, and respect the goals and interests of the student" (surgeon).

There are a number of people who had a large influence on my career and life and served as major role models and mentors to me. The first is Dr Ivan Brown, who was professor of surgery at Duke when I was a medical student. He was a major influence on my desire to enter cardiothoracic surgery, as were his colleagues, Drs Will Sealy and Glenn Young. Dr Billy Peete, a general surgeon at Duke, taught me about relationships with patients and their families and surgical technique. Dr David Sabiston set the standard for academic excellence, investigation, teaching, and research.

Dr William Waddell served as Chairman of the Department of Surgery at Colorado where I was a resident. He was a tremendous thinker and technician in the operating room and had superb clinical judgment, and I thank him for exposing me to these talents. Dr Thomas Starzl was the Chief of the Surgical Service at the Denver Veterans Affairs Medical Center (VAMC) during my residency and performed the first successful liver transplant. He had the combination of a brilliant mind and excellent surgical technique, and he was an outstanding translational researcher. Dr Ben Eiseman, who was Chief of Surgery at the Denver General Hospital at that time, was—and still is—a superb teacher, having a unique ability to stimulate young people and their minds. Very importantly, Dr Bruce Paton, a true renaissance man, was the Chief of Cardiothoracic Surgery during my residency in Colorado and he taught me not only how to operate but also how to maintain a good sense of humor, to remain humble, and to keep things in perspective. Both he and Dr Eiseman continue as mentors for me. Dr Henry Swan had stepped down as Chair of the Department of Surgery of the University of Colorado when I was a resident, but he brought a great sense of history to the department and demonstrated a keen scientific mind.

I am also very indebted to Rear Admiral Robert Lanning, my San Diego Naval Hospital Chief of Surgery. When he was Chief of Surgery at the Department of Veterans Affairs Central Office, he appointed me to the VA Cardiac Surgery Consultants Board, which stimulated my interest in the use of databases, quality improvement, and outcomes research.

For 19 years after my 2-year Navy commitment, I worked with Dr J. Kent Trinkle at the University of Texas Health Science Center at San Antonio. Kent had a tremendous influence on my professional development, teaching me how to think in an innovative fashion and take risks, but also to be very practical and keep things simple. I also appreciate the support of the Chair of the Department of Surgery at San Antonio, Dr J. Bradley Aust, who allowed me an incredible amount of freedom and support in the early and middle years of my career to develop clinical and research programs without interference.

I am also deeply indebted to Dr Alden Harken, an extremely well-rounded academic cardiothoracic surgeon, who gave me the leadership opportunity to be Head of the Division of Cardiothoracic Surgery at the University of Colorado, the Chief of the Surgical Service at the Denver VAMC, and to start a lung transplant program. I also appreciate very much the support of my longtime friend and colleague Dr Marvin Pomerantz, who was willing to come out of his private practice in Denver and join our university division to become our first Chief of the General Thoracic Surgery Section.

I am most grateful to my many faculty colleagues and residents in cardiothoracic surgery at San Antonio and Denver for all of their support and contributions over the years and for the many things that I have learned from them. I am very proud of them. I also want to acknowledge the tremendous support that I have had from my office and nursing staffs over my long career, some whom I have worked with for 15 to 25 years. I particularly appreciate the tremendous help I have had from my longtime clinical research colleague and collaborator, Dr Laurie Shroyer.

Finally, I want to express my appreciation to The Society of Thoracic Surgeons (STS) staff at the Chicago and Washington offices, led by our Executive Director Rob Wynbrandt, for their incredible support of the Society and me during 2006–2007. I cannot thank of all of them individually, but I would like to acknowledge the hard work and leadership of our six Directors: Joyce Gambino, Michael Hogan, Damon Marquis, Sylvia Novick, Nancy Puckett, and Cynthia Shewan. I would also like to thank the 350 to 400 volunteer cardiothoracic surgeons who are in leadership roles with the Society and who do so much for the betterment of our profession and the quality of care that we deliver to our patients. I particularly want to thank our officers, Doug Wood, Sid Levitsky, John Mayer, Ranny Chitwood, Doug Mathisen, and the Board and Executive Committee for their advice and help. I will acknowledge others throughout this address, but unfortunately, cannot acknowledge every individual who has been so important to this organization. Again, I thank you for all that you do.

Eleven years ago I gave my presidential address at the Southern Thoracic Surgical Association and titled it, "The Bright Future of Cardiothoracic Surgery in the Era of Changing Health Care Delivery," the same title I have chosen for today [2]. The circumstances were somewhat different, however. I began that address with the following introduction:

We are currently at a crossroads in our specialty and in the American health care delivery system and are facing many of the challenges that other industries in the United States faced as far back as the nineteenth century. We are experiencing an industrial revolution in medicine, as noted recently in the Wall Street Journal [3]. It is a watershed time for all of us, and the manner in which we approach the next five to ten years will deeply affect the future of our specialty. It is not unlike the opportunity that confronted the railroad industry at the beginning of this century when it continued to perceive itself as only a railroad industry and not as a transportation industry. Because of lack of vision, opportunities to expand into the air, trucking, and busing industries were missed, rendering this industry somewhat obsolete. This is similarly a period for cardiothoracic surgeons that requires considerable vision and reinvention to continue the productive and innovative work that has been characteristic of our specialty over the past several decades.

At that time, the change we were facing was the formation of multiple health maintenance organizations (HMOs) as an attempt to control health care expenditures. An article in The New York Times in December of 1993 [4] reported that health care expenditures for the United States were expected to exceed $1 trillion dollars the following year for the first time and approach 15% of the Gross National Product. The prevailing wisdom was that HMOs would help to contain these costs, but the major fear was that they would be very difficult for physicians to work with and decrease or limit the quality of care delivered. These concerns still persist, although thanks to database efforts to monitor quality of care and considerable outcomes research, quality of care has been protected but access to care and physician reimbursement has not. This revolution did, however, stimulate physicians and other health care providers to look hard for opportunities to control costs, resulted in standardization of procedures, the development of clinical pathways with some streamlining and standardizing of health care, and led to some increased efficiencies.

Although HMOs, inadequately funded Medicare and Medicaid programs, and lack of universal health care are ongoing challenges that still persist and are still extremely important, there are several more recent concerns that faced our specialty and me as I began my presidency in January 2006.

• The first issue was the challenge of expanding the scope of cardiothoracic surgical practice. This was compounded by several decades of successfully performing several procedures very well but not looking to expand the scope of practice and not having been as innovative as we should have been. The challenge, therefore, was for cardiothoracic surgeons to be involved in developing and learning new technology to broaden their scope of practice.

• The second is that of a tight job market, with a number of our graduating residents having difficulty finding jobs.

• The third is a shortfall of resident applicants, decreasing the number of residents nationally that we graduate, which in turn will contribute to a fourth issue, a significant shortage of cardiothoracic surgeons in the future. This will very negatively impact access to cardiothoracic surgery care and potentially the quality of care.

• The fifth challenge was to maintain and increase current procedures, by, for example, recouping some of the coronary bypass population.

• A sixth major challenge is decreasing reimbursement. There has been a more than 50% reduction in Medicare reimbursement for cardiothoracic surgical procedures over the past decade. This affects recruitment of residents into cardiothoracic surgery and will therefore have an impact on patient access and quality of care.

• A seventh issue is the need to update, grow, and modernize our databases. We also need to better define ethical relationships with industry, allowing for productive collaboration. Also important are developing closer relationships with other national and international professional societies, expanding our international relationships, and broadening our categories of membership.

The Society worked extremely hard during my presidency to address each of these issues. I will briefly review what we have accomplished in this regard and then address the challenges that we must face and manage in the near future.

Through the course of 2006–2007, the Society developed basic strategies to address these major issues. They were as follows: to be proactive, not reactive; to be involved wherever there was an opportunity to have a positive influence; and to develop an attitude that no issue is too big or too small to take on. The issues facing us required our efforts to effect a considerable amount of change. J. P. Kotter, in his book Leading Change [5], described an eight-stage process for creating major change. These steps are: "establishing a sense of urgency, creating the guiding coalition, developing a vision and strategy, communicating the change vision, empowering broad-based action, generating short term wins, consolidating gains and producing more change, and anchoring new approaches in the culture." He additionally noted, "an ineffective vision may be worse than no vision at all. Pursuit of a poorly developed vision can sometimes send people off a cliff. And lip service without commitment creates a sort of dangerous illusion."

Jim Collins, in his book Good to Great [6], makes several statements that I believe are applicable to what we applied during this course and what needs to be applied by the STS to bring our specialty from good to great. First, he noted that, "transformation is a process of buildup followed by breakthrough, broken into three broad stages: disciplined people, disciplined thought, and disciplined action." He also noted, "you must maintain unwavering faith that you can and will prevail in the end, regardless of the difficulties, and at the same time have the discipline to confront the most brutal facts of your current reality, whatever they may be." Another bit of advice from this book: "... if you cannot be the best in the world at your core business, then your core business absolutely cannot form the basis of a great company" (in our case specialty). And then another word of advice: "...when you combine a culture of discipline with an ethic of entrepreneurship, you get the magical alchemy of great performance." He further states, "no matter how dramatic the end result, the good to great transformations never happen in one fell swoop. There is no single defining action, no grand program, no one killer innovation, no solitary lucky break, and no miracle movement. Rather the process resembles relentlessly pushing a giant heavy flywheel in one direction, turn upon turn, building momentum until a point of breakthrough, and beyond."

	Accomplishments During 2006–2007

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 
Taking the advice of the above authors, I will describe how the Society and our specialty addressed many of these issues during my presidential year, what the accomplishments have been, and then outline what, in my opinion, are some of the major and critical issues still facing us that we must constructively manage in order to move the specialty forward to continue to improve the care of our patients.

One of the first things that the STS accomplished in the spring of 2006 was to approve a new strategic plan. The plan had been in development for more than a year and identified eight strategic goals and a new mission statement. The new mission statement is for the STS "to enhance the ability of cardiothoracic surgeons to provide the highest quality patient care through education, research, and advocacy." The mission is appropriately patient focused. Our reason for being is to develop and deliver the highest quality of patient care possible, and we must never forget this.

The strategic goals are as follows:

1 Focus STS education programs on new technologies and procedures needed by members to provide clinical care in an expanded scope of practice.

2 Work with payors, government agencies, and quality improvement organizations to shape policies that advance the profession and ensure patient access, quality care, and fair reimbursement.

3 Advocate for the interests and fulfill the needs of cardiothoracic surgical residents.

4 Promote an accurate understanding of the specialty, its career path options, and its rewards among the diverse population of medical students, potential residents, and current residents.

5 Increase member participation in STS databases by educating members on the value and appreciation of database information to practice, payment, quality improvement, and coverage.

6 Expand database capabilities to include long-term outcomes and costs and to interface with other domestic and international databases.

7 Protect and expand the scope of cardiothoracic practice.

8 Educate patient and consumer organizations, payors, and purchasers about the value of the cardiothoracic surgeon in the management of cardiothoracic diseases.

Many of these strategic goals address the issues that were identified as critical at the beginning of my presidential year. The strategic plan process allowed us to focus on strategies to deal with those issues using our council and workforce structure with our volunteer cardiothoracic surgeons and our 32 professional staffers.

One of the first challenges was to expand the scope of practice. This is being addressed by educational programs at our 2007 Annual Meeting under the Council on Education and Member Services chaired by John Conte and Program Chair John Calhoon, emphasizing new technologies and treatments in our regular program, Tech-Con, and the STS University. These groups are identifying a wide variety of new and emerging technologies and procedures that need to be applied to a broadened scope of cardiothoracic surgical practice, which include percutaneous valve technology, radiofrequency ablation of lung tumors, endobronchial lung volume reduction, laparoscopic esophageal surgery, thoracoscopic lobectomy, minimally invasive valve replacement and repair, aortic endografting, catheter-based techniques, robotics, and many others. In addition, the Society has established freestanding educational meetings that have included endovascular courses directed by Nick Kouchoukos.

I am pleased to announce that the STS, for the first time in its history, has partnered with industry to endorse courses. We have partnered with Medtronic on the Medtronic Edge Course, which uses a well-equipped Medtronic laboratory with simulators to train our members and residents on basic catheter skills. Clinical fellowship training is also being developed and coordinated by this council. The first STS-Medtronic Edge Course took place in November 2006, and it will be offered monthly. We have also recently signed agreements with Edwards for a similar basic catheter skills course and with the American College of Cardiology (ACC) for a jointly sponsored valve course, and we have partnered with the American College of Chest Physicians on a general thoracic surgery course. We hope that this is just the beginning of much collaboration to ramp up our education in new and advancing technology to provide the necessary skill sets for success.

The opportunity for industry collaboration was very nicely stated by Drs Stuge and Liddicoat, from Medtronic Inc, in a recently published paper emphasizing that emerging technologies will increase procedural demand, including open and minimally invasive procedures [7]. They stress the importance of catheter-based skills, the importance of a multidisciplinary approach, and the fact that cardiac surgeons are most familiar with the anatomy and physiology of the heart and great vessels, are available to do the operations, and are best able to handle any complications that arise. We look forward to partnering with Medtronics, Edwards, and other companies who come forward.

The STS Officers have also met with the officers of other professional societies, including the Society for Vascular Surgery (SVS), for potential training and credentialing, and the ACC for potential areas of collaboration. Cross training of residents and fellows in catheter techniques is a necessary skill for thoracic endografting and minimally invasive or percutaneous valve replacement.

A second major issue that we addressed was the tight job market for graduating residents. In response to this, this STS developed a Career Connections Program very soon after the Annual Meeting in January 2006 under the guidance of Drs Walter Merrill and Robert Higgins. Questionnaires were developed for graduating residents to fill out with information including their training, special interests, and future goals, and a mirror image form was developed for prospective employers to fill out with the characteristics they want in a candidate. The candidates’ and employers’ forms are matched in the STS office for alignment of mutual interests, and then the name of the applicant is given to the potential group seeking a cardiothoracic surgeon.

In addition to the long-standing residents’ luncheon at the Annual Meeting, we initiated a residents’ symposium at the 2007 San Diego meeting. The Workforce on Graduate Medical Education is developing a residents’ section in the STS Web site to provide online resources, particularly with regard to job offers for current residents. We are asking for resident involvement in planning educational programs and are expanding the numbers of residents who become candidate members of the STS. In addition, we are appointing more resident candidate members to STS workforces and task forces in an effort to involve them at a grassroots level to enable their needs to become immediately known.

We are attempting to better prepare and train our residents in new technology and offered scholarships to 14 residents and fellows for the July 2006 Endografting Symposium. Scholarships will continue to be offered for other STS courses. Resident issues were made a focus of our 2006 Legislative Advocacy Workshop in Washington, and we hope to achieve scholarship sponsors to bring some of our residents to the annual Workshop. The Workforce on Graduate Medical Education is also developing an online help desk for graduating residents with questions.

A third major issue of critical concern is the shortfall in cardiothoracic resident applicants. Figure 1 shows the changes in Graduate Medical Education positions filled by United States physicians from 1998 to 2004 [8]. Note the decrease for cardiothoracic surgery, but also the encouraging increase for anesthesiology, which went through a similar shortfall in the mid-1990s. During the past match, only 91 of 126 positions were filled for July 2007 (Fig 2) [8].

View larger version (15K): [in this window] [in a new window]   Fig 1. Change in graduate medical education (GME) positions filled by United States medical doctors from 1998 to 2004 is shown with a decrease in cardiothoracic surgery along with four other specialties. Note however, the marked increase in anesthesiology after the period of the mid-1990s when they experienced difficulty in filling their positions, which resulted in a shortfall of anesthesiologists. (CT = cardiothoracic; GI = gastrointestinal; IM = internal medicine.) (National GME Census [American Association of Medical Colleges and American Medical Association]. © 2007 Association of American Medical Colleges. All Rights Reserved. Reproduced with permission.)

View larger version (22K): [in this window] [in a new window]   Fig 2. Applicants to thoracic surgery resident programs, 1993 to 2007. Note the decrease in total (circles) and United States medical graduate applicants (triangles) for thoracic surgery resident programs during the past 3 years compared with active positions available (squares). Only 91 of 126 positions filled for this past year for residents beginning in July 2007. (From National Residents Matching Program (NMRP), Results and Data Main Residency Match, 1990–2005, reprinted with permission.)

The Workforce on Graduate Medical Education, under Walter Merrill’s leadership, is working with the Thoracic Surgery Directory Association to offer online resources such as a virtual cardiothoracic surgery interest club and is developing online video clips to encourage an interest in cardiothoracic surgery among medical students and college and high school students.

The American Association for Thoracic Surgery (AATS) and STS are establishing an extremely important Task Force on the Recruitment of Woman into Cardiothoracic Surgery to be chaired by A. J. Carpenter. Upwards of 50% of our current medical graduates are women, many of whom are excellent students. Unfortunately, less than 5% of cardiothoracic surgeons are female, which means our specialty is missing out on many of the best and brightest. Reasons for this will be determined, and then the issue will be vigorously addressed.

Each of us, however, has an individual responsibility to encourage college and medical students and general surgery residents to enter a career in cardiothoracic surgery. As we all know, mentorship is extremely important, and all of us, particularly those of us in practice in academic medical centers, have the opportunity and duty to mentor young people and expose them to the excitement and gratification of what we do on a daily basis. It is only with this grassroots type of effort that we will again have a full complement of bright, young, vigorous, and passionate residents.

One of the impediments to medical students and general surgery residents to choosing a residency in cardiothoracic surgery is the average loan debt burden of $100,000 to $150,000 when finishing medical school. The STS worked closely with Congress this past year to get medical student loan debt relief for these students. This bill passed the House as HR609 but was not voted on in the Senate. We will pursue this again this congressional session.

Another potential factor in this shortage of resident applicants has been the declining reimbursement for cardiothoracic procedures during the past 10 years. We are pleased to report, however, that this year, under the leadership of Dr Peter Smith’s Nomenclature and Coding Workforce, and the Relative Value Update Committee (RUC) process, reimbursement was significantly increased for cardiothoracic surgical procedures. We also worked with Congress and Senator Frist to eliminate the planned across-the-board Medicare Sustainable Growth Rate (SGR) 5.1% reimbursement cut, and we worked very hard with the Centers for Medicare & Medicaid Services (CMS), other payors, and Congress to influence the methodology for pay for performance, realizing that with our database in place, cardiothoracic surgeons are in an excellent position to take advantage of pay for performance programs. The Society’s actions addressing decreasing reimbursement will be discussed in more detail later.

The STS held a press conference on the Capitol steps on match day to publicize the critical nature of the resident matching shortage. Doug Mathisen spoke for the STS, and our own member and Congressional Representative, Charles Boustany, was very active in this effort.

We are very concerned that this shortfall in resident applicants will exacerbate an already predicted shortage of cardiothoracic surgeons in the next 10 to 15 years and create a major public health crisis for access to and quality of care for patients in need of cardiothoracic procedures. The STS and the AATS therefore contracted with the American Association of Medical Colleges (AAMC) to perform an independent workforce analysis for cardiothoracic surgery with predictions well into the future [Atul Grover, American Association of Medical Colleges Workforce Analysis for Cardiothoracic Surgery, personal communication, 2007]. This effort is headed by Dr Atul Grover. They have noted a decrease in cardiothoracic surgeons in 2004 and 2005 (Fig 3) [9]. In addition, there are many surgeons practicing who are older than 55, many of whom are predicted to retire in the next 5 to 10 years (Fig 4). This study predicts a shortfall of 2400 cardiothoracic surgeons by 2005 if baseline supply and demand is assumed, but if only 75 residents finish each year, this would create a shortage of 3000 surgeons by 2025 (Fig 5). Presently, there are fewer than 5000 practicing cardiothoracic surgeons, so that this represents a 60% shortfall in work force. Their group finds that even if the coronary bypass operation were eliminated, there would still be a shortage of cardiothoracic surgeons.

View larger version (10K): [in this window] [in a new window]   Fig 3. Number of active thoracic surgeons, 1990 to 2004. This graph demonstrates a decrease in active cardiothoracic surgeons during the past 2 years, decreasing from approximately 5100 to just slightly over 4000. (American Medical Association Masterfile, 2006 includes physicians self-designating as cardiovascular surgery, cardiothoracic surgery, and thoracic surgery.) (© 2007 Association of American Medical Colleges. All Rights Reserved. Reproduced with permission.)

View larger version (27K): [in this window] [in a new window]   Fig 4. Age distribution of cardiothoracic surgeons shows those who are in clinical practice (black), nonclinical practice (white), and those who are residents (gray). This graph from the American Association of Medical Colleges Committee on Workforce for Cardiothoracic Surgery demonstrates the large number practicing cardiothoracic surgeons older than 55 years and even older than 65. (American Medical Association Masterfile. January 1, 2006. American Medical Association.) (© 2007 Association of American Medical Colleges. All Rights Reserved. Reproduced with permission.)

View larger version (15K): [in this window] [in a new window]   Fig 5. An additional 3000 surgeons will be needed if thoracic surgery residents fall to 75 per year (triangles). Note the shortfall of 3000 surgeons by 2025 if only 75 residents per year are matched into thoracic surgery residency programs. (Baseline demand, dashed line.) (A Grover, American Association of Medical Colleges Workforce Analysis for Cardiothoracic Surgery, personal communication, 2007.)

View larger version (32K): [in this window] [in a new window]   Fig 6. Workforce anesthesiology positions filled by using the National Resident Matching Program (NRMP) during the years 1990 to 2005. Note the decrease in recruitment of anesthesiology residents during the mid-1990s compared with all residents (dark gray), with a 4-year consecutive decrease in resident matching and the 6-year recovery period. (CA-1 = clinical anesthesia level 1, medium gray; PG-1, postgraduate year, light gray.) (From National Residents Matching Program (NMRP), Results and Data Main Residency Match, 1990–2005, reprinted with permission.)

The next challenge that we faced this past year was that of protecting existing procedures and growing their volume. The establishment of evidence-based guidelines is important in establishing appropriateness of care for various diseases, which will influence which patients get which treatments or procedures. The STS Evidence Based Guidelines Workforce, chaired by Charles Bridges, publishes guidelines for cardiothoracic diseases where cardiothoracic surgery has a role. In addition, the STS has been working closely with the AATS to identify cardiothoracic surgeons to be placed on the ACC/AHA (American Heart Association) guideline committees. We are currently going to be one of the major contributors to an ACC/AHA/STS guideline on thoracic aortic endografting and are working with ACC/AHA leadership and staff to have a more prominent role in future guidelines, including equal leadership recognition when appropriate, such as with the ACC/AHA/STS guidelines.

The Workforce on Clinical Education is assigning surgeons to review relevant scientific literature as it is published, to identify articles that should be challenged, and to write letters based on the best available evidence. Dr Robert Guyton, Chair of the Presidential Task Force on Communication, recently wrote a letter to Circulation with several of us as cosigners objecting to a very biased and scientifically inadequate study of transapical percutaneous aortic valve replacement. This task force is charged with communicating the importance of the role of cardiothoracic surgeons in treating cardiothoracic diseases in the adult and pediatric populations to the medical community, government, and the public.

In addition, Richard Shemin’s Workforce on Adult Cardiac Surgery has a special task force addressing the issue of 3-vessel and left main coronary artery stenting compared with the long-term results of coronary artery bypass and reviewing all articles and research proposals on that topic for the validity or lack thereof of scientific design. This task force is coauthoring an internationally authored paper that will soon be published comparing the short-term and long-term efficacy and effectiveness of coronary bypass vs stenting in patients with advanced coronary disease.

Many of you heard Professor Taggart’s Ferguson Lecture at the 2006 STS Annual Meeting, a lecture of his earlier at this year’s meeting, and one at the Western Thoracic Surgical Association in June 2006. Owing to efforts of the leadership of the STS and ACC, Dr Taggart participated in a debate at the Annual Meeting of the ACC in March 2007, again comparing short-term and long-term results of coronary artery bypass grafting (CABG) vs stenting. In an effort to further educate organizations and consumers about what we do, we are working with many organizations in the public and governmental areas, quality organizations, and professional societies, including the AHA, the ACC, the American College of Chest Physicians (ACCP), the SVS, and the American College of Surgeons (ACS), by communicating cardiothoracic surgical efficacy and surgical outcomes, demonstrating the high quality of care delivered. It is our goal to develop educational materials, including downloadable brochures and Power Point presentations, for our members to use when speaking to patient, consumer, payor, purchaser, and legislative groups.

One of the more important events that occurred this past year was that the STS was being invited to testify before the United States Food and Drug Administration (FDA) on the drug-eluting stent issue. This group was organized by the Task Force on Stenting vs CABG for Left Main and Three Vessel Disease. Under the guidance of Richard Shemin and Mike Mack, along with the help of our Washington office staff, four 15-minute presentations were organized and given by Peter Smith, Robert Guyton, Bruce Ferguson, and myself documenting the evidence basis for better outcomes for coronary bypass surgery compared with stents at 5 years in patients with high-risk 3-vessel coronary artery disease.

The group also had the opportunity to highlight the issue of lack of informed consent involving patients undergoing interventional cardiology procedures, noting that they often were not informed of the superiority of coronary bypass in terms of long-term mortality, and pointing out the rampant off-label usage of stents in the high-risk patients who were seldom included in the randomized trials. Premarketing studies were shown to be underpowered, populated with low-risk patients, and highly selective, with only 4% of eligible patients being entered. Evidence was presented demonstrating significantly better late survival with coronary bypass in patients with high severity coronary artery disease (Figs 7 and 8) [11, 12].

View larger version (13K): [in this window] [in a new window]   Fig 7. Adjusted survival in patients with percutaneous coronary intervention (PCI; black line) with bare-metal stents vs coronary artery bypass grafting (CABG; gray line). This graph demonstrates a significant survival advantage of patients who had high severity coronary artery disease treated with CABG compared with stents at Duke University from 1996 to 2000. (Smith PK. Relative merits and clinical selection of CABG, bare metal stents, and drug eluting stents in practice and in evolution. Testimony before the US Food and Drug Administration, Circulatory System Devices Advisory Panel, December 8, 2006.)

View larger version (11K): [in this window] [in a new window]   Fig 8. The New York State data from 1997 to 2000 for 3-vessel coronary artery disease (N = 23,022) is very similar to the Duke data in Fig 7 that demonstrates a significant survival advantage for patients treated with coronary bypass (CABG, grey line) compared with stents (black line) at 3 years. (From Hannan EL, Racz MJ, Walford G, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med 2005;352:2174–83. Copyright © 2005 Massachusetts Medical Society. All rights reserved.)

One of most fair and unbiased panelists was the ACC President, Dr Steven Nissen, who also expressed concerns about the widespread use of these devices in these high-risk patients without an adequate evidence base. We all must keep in mind that what is of paramount importance is that each given patient receive the therapy that is most appropriate. In some patients, that will be stents; in others, CABG. Currently, there are many patients receiving stents inappropriately—many without informed consent—and that is wrong, medically, morally, and ethically. Both the STS and ACC offered to perform long-term surveillance of outcomes for CABG and stents, respectively, and are exploring a potential collaboration with CMS as an initial means to "jump-start" our ability to track outcomes up to 5 years postprocedurally.

We concluded that off-label use of stents is unproven, and that patients must be better informed of treatment options and the relative risks and benefits of medical therapy, percutaneous coronary interventions, and CABG. The STS recommended to the FDA that:

1 A labeling change be made for drug-eluting stents to reflect the fact that the safety and effectiveness of stenting in multivessel disease has not been established.

2 Adequate informed consent be given to patients regarding all treatment options by a multidisciplinary team before catheter intervention is performed.

3 Robust comprehensive databases be developed to determine appropriate therapy in various subsets of patients with coronary artery disease.

4 A stronger FDA/specialty society partnership be developed using the strengths of the FDA, the STS, the ACC, and the medical device industry.

Subsequently, an article appeared in the January 23, 2007 issue of the Wall Street Journal expressing growing sentiment regarding the overuse of drug-eluting stents [14]. Several of our members met with FDA officials that same day, and we are hopeful to have an increased role with the FDA in both premarketing and postmarketing evaluations of new technology.

Another major issue facing cardiothoracic surgery since the early 1990s has been the reduction in reimbursement. Figure 9 demonstrates the significant reduction in reimbursement in dollars with and without Consumer Price Index adjustment. These reductions have been draconian, and the STS has put a very high priority on addressing this issue. To that end, an excellent Legislative Advocacy Workshop was held in September 2006 with attendance of approximately 50 of our members who visited their own congressional delegations. Mark McClellan, the extremely competent and bright director of CMS, was one of our featured speakers, along with Congressman Pete Stark, who is now chairing the Health Subcommittee of the House Ways and Means Committee, and our own Senator Bill Frist, who spoke to us for about 45 minutes immediately after closing the Senate at a reception hosted by the STS in the Capitol. Senator Frist has a long record of being understanding and supportive of medicine’s and cardiothoracic surgeons’ concerns in Congress, and we appreciate his efforts very much during his 12 years of service in the Senate.

View larger version (15K): [in this window] [in a new window]   Fig 9. Medicare payment trend for coronary artery bypass graft procedures in real dollars (triangles) and dollars adjusted to the Consumer Price Index (CPI; squares). The marked reduction in reimbursement both in real dollars) in inflationary-adjusted dollars for Medicare reimbursement for coronary bypass for patients is demonstrated over the past 10 years. (Medicare data from the Physician Fee Schedule.)

The STS placed a high priority on trying to influence Congress and CMS’s policy on pay for performance. Dr Jeff Rich testified twice before the Health Subcommittee of the House Ways and Means Committee on the use of the STS Database as an instrument of improving quality, which would create cost savings that could be applied to the Pay for Performance Program. He described the Virginia Demonstration Project where the STS Database is linked to the CMS UB-92 Cost Database. Dr Rich demonstrated the relative differences in hospital costs for coronary bypass procedures, noting that the hospitals with the lowest observed-to-expected mortality ratio had the lowest costs, implying that high quality is usually more cost-effective (Fig 10). He then showed the costs of various complications after coronary bypass, demonstrating, for example, that hospital costs for a patient who had renal failure would be $57,000 compared with $19,000 for a patient with no complications (Fig 11). Projecting these data, Jeff made the case that if one could decrease complications nationally for coronary bypass procedures by 10%, this would create an annual savings of $346 million, and this amount of savings could then be applied to pay for performance bonuses as dollars added to the system. Jeff and I gave a similar presentation to an Institute of Medicine Subcommittee on Pay for Performance [16].

View larger version (43K): [in this window] [in a new window]   Fig 10. The total cost by hospital for coronary artery bypass grafting (CABG) procedures in the Virginia Demonstration Project as well as the observed-to-expected mortality ratios. Of interest is that the hospitals with the lowest observed outcome/expected outcome (O/E) ratios (ie, the best outcome) have the lowest cost. (VCSQI, Virginia Cardiac Surgery Quality Initiative (Rich, Jeffrey B; March 15, 2005, Testimony before the U.S. House of Representatives, Committee on Ways and Means.)

View larger version (43K): [in this window] [in a new window]   Fig 11. Cost-savings are possible from improvements. The incremental cost of various complications is demonstrated compared with the cost of patients with no complications. This shows the tremendous impact of morbidity on hospital costs. (Rich, Jeffrey B; March 15, 2005, Testimony before the U.S. House of Representatives, Committee on Ways and Means.)

View larger version (11K): [in this window] [in a new window]   Fig 12. The Relative Value Update Committee (RUC) recommended intraservice work per unit of time (IWPUT) values (diamonds) for various adult cardiac and general thoracic surgical codes are shown compared with the original proposed Centers for Medicare & Medicaid Services (CMS) values (squares), which were much lower. Fortunately, CMS reversed its position and agreed to the RUC recommendation for reimbursement. (Department of Health and Human Services Centers for Medicare & Medicaid Services CMS-1512-PN RIN 0938-A022 Medicare Program: Five-year Review of Work Relative Value Units Under the Physician Fee Schedule and Proposed Changes to the Practice Expense Methodology.)

The leadership of the STS believes that we need to modernize, update, and continue to grow our databases as a major initiative. To this end, a Task Force on Modernization of the Databases has been established. The databases are integral to the very fabric of the STS and our specialty and are used by all of the STS Councils. They have set the STS and cardiothoracic surgery apart from all other professional organizations and specialties. The databases have given us an entrée to Congress, the Executive Branch, CMS, payors, purchasers, and the major quality improvement organizations, and will be effective in our communication with the public. They are essential for continuing quality improvement and should be useful in recertification.

Currently, the Adult Cardiac Surgery Database, chaired by Fred Edwards, has 776 participants, close to 80% of all adult cardiac surgical programs. More than 3 million surgical procedures are included, and in the past 10 years, 1.6 million isolated CABG operations have been entered. Data auditing has been completed at 24 sites this past year, and the adult cardiac surgery database is endorsed by the National Quality Forum (NQF) and the Ambulatory Quality Alliance (AQA) as well as by several hospital and payor systems. One of the most remarkable accomplishments in the past 15 years has been the marked reduction in risk-adjusted mortality in increasingly higher-risk patients, as shown in these two graphs of CABG patients, the first over the decade of the 1990s and the second the first 5 years of this century (Figs 13 and 14).

View larger version (9K): [in this window] [in a new window]   Fig 13. Observed-to-expected ratio for all isolated coronary artery bypass graft patients (CABG) from 1990 to 1999. Graph shows the results of logistic modeling for patient risk. The change over the decade is statistically significant, with p < 0.0001 for time trend (1990-1999). Note the very significant decrease in observed-to-expected mortality ratios for CABG patients for the decade of the 1990s.

View larger version (6K): [in this window] [in a new window]   Fig 14. Observed-to-expected ratio for all isolated coronary artery bypass grafting (CABG) patients from 2000 to 2005 (p < 0.0001 for time trend). Graph shows results of logistic modeling, adjusting for patient risk. Note a similar reduction in observed-to-expected mortality ratios for CABG patients during the first 5 years of this century.

Forty-eight groups participated in the Congenital Cardiac Surgery Database, chaired by Jeff Jacobs. The sixth harvest occurred last spring. More than 45,000 operations have been submitted. Risk adjustment has been carried out by an integration of the Aristotle and Risk Adjustment in Congenital Heart Surgery (RACHS-1) Scores. An audit is being initiated shortly.

One of the strategies has been to involve the STS and the STS Databases as much as possible in all of the various quality and payor groups that will be involved with public reporting and pay for performance programs. These many organizations are the NQF, the AQA, the Hospital Quality Alliance (HQA), the AQA-HQA Steering Committee, the Surgical Quality Alliance, the Physician Consortium for Performance Improvement, and the CMS Physician Voluntary Reporting Program. We are attempting to be at as many tables as possible to, hopefully, direct health care policy in a positive manner to improve patient care and access to care. The STS is primarily represented at these groups by Fred Edwards and Jeff Rich. In addition, we have representatives on the quality boards of several payors and states.

The STS has been working with Wellpoint, Blue Cross Blue Shield, and United Healthcare to use STS Databases to measure cardiothoracic surgical performance. The potential advantages of this are that it is voluntary; it allows one mechanism for all payors vs multiple different mechanisms with different data elements; it is a scientifically and methodologically sound system; the statistical analysis will be rigorous, using STS/Duke Clinical Research Institute (DCRI); and it will use clinical data rather than inaccurate administrative data. We will use a rating rather than a ranking system. The STS will be initially informed of any program in trouble and allowed to work with that program. It will position cardiothoracic surgeons to define how performance is evaluated, and it will be important if and when pay for performance becomes a reality. Many of the insurers and hospital chains will be demanding data demonstrating quality in order to be a member of their payor programs or for pay for performance. Our databases can be part of a CMS pay for performance if Congress eventually endorses that policy. Therefore, every member needs to seriously participate in the databases that cover the scope of their practice. Quite frankly, if we do not assume this role, someone else will, and it will not be good.

For the modernization of the databases, we hope to increase the use of the Web, facilitate timely addition and deletion of data fields, introduce new modules, interface with other databases such as the ACC Database, capture long-term outcomes, develop risk-adjusted cost analysis, audit all databases, and relate the databases to the patient safety program that was so nicely outlined by Thor Sundt and his Workforce on Patient Safety in the STS Newsletter several months ago.

	Industry Relationships

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 
There were several notable examples of conflicts of interest between physicians and industry this past year, some involving cardiothoracic surgeons. It is important that we continue our close collaboration with industry because that is how new technology is developed that can improve the care of our patients and broaden the scope of our practice. The STS and the AATS must be involved with guidelines for the rules of engagement in these processes so that the conflicts of interest are minimized or at least transparent to ensure public trust. The Standards and Ethics Committee has developed such guidelines.

	International Relationships

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 
A major goal of the STS is to expand our international relationships. Expansion of international relationships is necessary, as the world becomes smaller and medical care more global. We have established close relationships with the European Association for Cardiothoracic Surgery (EACTS) and the European Society of Thoracic Surgeons (ESTS). We need to expand these efforts to other regions of the world to learn from them and to share our knowledge with our colleagues in those areas. Of note, we approved a process at the January 2006 meeting whereby members of the EACTS can become members of the STS by virtue of their EACTS membership. I am pleased to report that at the business meeting of the EACTS in Stockholm, the reciprocal agreement was approved enabling STS membership to suffice as criteria for membership into EACTS. This will promote an even closer relationship between the STS and EACTS. Several of our leadership, including myself, have participated in international meetings during the year. I was pleased to participate in an ESTS meeting in Cluj, Romania, in the spring, in the EACTS meeting in Stockholm in September, and the Japanese Association for Cardiothoracic Surgery in Tokyo in October. Several of our officers visited with officers of the Asian Society of Cardiovascular Surgery in September about a potentially closer relationship. We will be voting later today on reducing dues and fees for potential STS members from low- or lower-middle-income countries. Dr Jack Matloff chairs the Workforce on International Relationships, which organizes an international program at our Annual Meetings.

Of great importance is our reaching out to work with physicians in developing nations for teaching and service. Members, including Senator Frist, myself, and many others have participated in medical trips to other parts of the world, including developing nations, and have found them to be very valuable and educational. I invited Nepal’s two cardiothoracic surgeons, Drs Pokhrel and Koirala, whose work I admire very much, to this year’s meeting. I have enjoyed operating and rounding with them and participating in teaching conferences. Our church has helped to create an 80-bed pediatric ward at Patan Hospital in Nepal as well. I encourage all of you to become involved in this type of activity. I want to emphasize the importance of such efforts, as has Senator Frist, not only for their humanitarian and educational value but also to build strong relationships and goodwill around the world.

One of our challenges is to be more inclusive, and this past year under Dr Levitsky’s presidency we incorporated PhD scientists performing research in the area of cardiothoracic surgery into our membership. Bylaw changes were approved at our 2007 Annual Membership Meeting to include other members of the cardiothoracic surgical team, such as perfusionists, operating room nurses, nurse coordinators, nurse practitioners, physician’s assistants, and STS Data Managers as associate members.

We have reached out this year to other US professional societies, with our officers meeting with the officers of the ACC, SVS, and ACCP, in addition to our three times a year meetings with the officers of the AATS, the EACTS, and the ESTS. We have collaborated on educational issues, health care policy, research, and quality improvement. One of the positive outcomes of the meeting with the ACC leadership was an agreement that cardiothoracic surgeons would have a greater role in their educational programs and leadership and an increasing role in guidelines development. The success of cardiothoracic surgery and cardiology are mutually tied together, and there is much to be gained by a close collaborative relationship, particularly in the quality of care that we deliver to our patients and defining appropriateness of care.

The meeting with the officers of the SVS went well, touching on difficult issues, including scope of practices for both specialties, training of residents with the potential for integrating some of the training of our respective residents, and credentialing for vascular stenting procedures. An outcome of that meeting was the creation of two task forces, one on resident education and one on credentialing, which will have equal representation by both the SVS leadership and STS leadership. Dr Bruce Lytle will represent the AATS on the Residency Task Force.

At the meeting with the ACCP, we agreed to continue STS participation in joint ACCP/STS courses, and we also discussed in some detail the differences that we have had between the two organizations during the RUC proceedings regarding critical care of cardiothoracic surgery patients. It is hopeful that through these discussions we will have a more unified approach to our health policy issues.

Our relationship with the AATS has been exceedingly good. Bruce Lytle and I have communicated on many issues, and Bruce has been very helpful in getting our input into appointments for the ACC/AHA Practice Guideline Committees. We have tried to align the two organizations in the area of public policy and have tried not to be duplicative in the areas of education.

We need to reach out to even more groups to develop more collaborative relationships to coordinate education, public policy efforts, research, and quality of care. We have been approached by the Society of University Surgeons and the American Surgical Association to promote more involvement of thoracic surgeons in their organizations and meetings. We have participated in the inauguration of our own Bill Plested as the American Medical Association (AMA) President and have tried to be more actively involved with the AMA, working with them on many of the quality issues and organizations in Washington. We have an excellent relationship with the ACS, and our offices are located in their building in Chicago. I believe that we should also have a meeting with their officers, and executive director and our officers, at least once a year to find areas of common interest in which we can collaborate, particularly in education and health policy. We are very likely going to locate our Washington office in a building that is being constructed by the ACS just a few blocks from the Capitol. This should further enhance our relationship and communication with the ACS. All of these efforts are very important and need to be pursued.

	Challenges and Opportunities

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 
In my opinion there are six major issues facing cardiothoracic surgery this coming year. The first is that we must continue to educate our members and residents on new technology and science. It is the future, and in several years, the specialty will be very different from the way we know it now. We must provide ongoing educational programs that teach new technology, not only at our annual meeting but also at numerous freestanding meetings. We must partner with industry, other professional societies, and local institutions to develop and carry out these courses, and most importantly, we must identify clinical training opportunities following these didactic and laboratory simulator courses.

The second challenge is that it is not enough, however, to just learn the techniques and the new science that others have developed. We as a specialty need to re-create the culture of the 1950s, 60s, and 70s and participate in the development of new techniques and the advancement of science with new ideas. We need to protect the time of our young and mid-level surgeons to do just that. Too often, they are performing procedures in the operating room 5 days a week, with very little time for creative thought, research, and innovation. It is up to those of us in academic leadership positions to somehow effect change in this regard. Without that, our specialty will be intellectually bankrupt. We also must continue to work with the AATS to lobby and advocate for increased research funding.

The third major issue is the recruitment of the best and brightest residents into cardiothoracic surgery and addressing the impending workforce crisis. What can we as the current cardiothoracic surgeons do to increase the interest of young medical students and general surgery residents in the specialty of cardiothoracic surgery? As noted earlier, this past year we filled only 91 of 126 positions for July 2007. We must increase the exposure of medical students and general surgery residents to cardiothoracic surgery. We must collaborate with the AATS, the Thoracic Surgery Residency Program Directors Association, and the American Board of Thoracic Surgery to educate the AAMC leadership and the deans of all the medical schools that have thoracic surgery residency training programs about the cardiothoracic surgery workforce crisis in an effort to gain exposure in the medical school curriculum. Medical students beginning at the freshman year must be exposed to cardiothoracic surgery, both by didactic lectures and clinical observation. We must also educate the General Surgery Residency Review Committee, the American Board of Surgery, and the general surgery residency program directors on the absolute necessity of early level exposure of general surgery residents to cardiothoracic surgery.

We have to improve our mentoring of medical students and general surgery residents and improve their educational experience on cardiothoracic surgical rotations. When general surgery residents rotate on cardiothoracic surgery, they must be given a meaningful experience, not secretarial and menial work.

Fourth, we must also be certain that we provide an excellent educational experience for our cardiothoracic surgical residents. I want to emphasize that cardiothoracic residents must be central, not peripheral, to clinical activities; in other words, not marginalized. Residents must be involved in preoperative decision making, perform the vast majority of procedures, direct postoperative care, and be involved in out-patient follow-up. We must have collegial relationships between faculty and residents. As teachers we must teach, not only the techniques of surgery but also didactic information, decision making, professionalism, communication, and medical ethics. We must be involved as role models and mentors. We must be the residents’ advocates, including helping them find employment and advanced training opportunities. A recent study conducted by Bob Higgins and Walter Merrill and the Workforce on Postgraduate Medical Education found that residents feel that program directors and other faculty are one of the most important if not the most important factor in job placement [personal communication]. As we train residents, it is our responsibility to be sure that they are competent, to help them find a position, and promote a successful career for them. If we accomplish this, our residents will be better trained and happier, and the field will be more attractive to applicants. Our specialty’s future is in our residents, and in general, I believe as a specialty we need to pay more attention to that great responsibility.

My fifth point is that total participation in the STS Databases is required. This is necessary for continuous quality improvement, public reporting, pay for participation, pay for performance, to be successful in RUC and reimbursement, to communicate the value of what we do for health care, and to monitor the results of new technologies. For all of these reasons, I strongly believe that not participating in our databases is not an option; nonparticipation is detrimental to our patients and to our specialty!

Sixth, we must have a high level of member support of both time and money to continue to increase our effectiveness and influence in health care policy, quality improvement, and education. To put this into perspective, some of our health policy achievements in 2006 include increased Medicare reimbursement of $42 million to the specialty and prevention of across-the-board physician payment cuts, a savings of $40 million to the specialty. The STS National Database is a quality measurement platform for Medicare payment for 2008 and will create an extra 1.5% reimbursement for some procedures. A medical student’s Loan Forgiveness Bill was passed in the House, giving us hope for the future legislation. We testified before the FDA on the risk of drug-eluting stents used in patients with multivessel disease. This may ultimately increase CABG referrals.

Although we have accomplished a lot this past year, the legislative challenges that we face include:

• Again repealing the Medicare payment formula to prevent 31% in cuts over the next 5 years.

• Recouping clinical staff costs, (practice expenses) estimated at $75 million per year.

• Ensuring that the STS continues to control data.

• Ensuring compensation for reporting.

• Further defining appropriate therapy for multivessel coronary artery patients including informed consent.

• Addressing the decline in cardiothoracic surgery resident applicants by obtaining debt relief from medical school loans.

The relative political action committee (PAC) contributions of thoracic surgeons compared with several other specialties and the trial lawyers are shown (Fig 13, 15). We need to do better! Only 14% of our members contribute to the PAC, a fund that does so much to gain access for us to Congress and facilitates our participation in governmental affairs (Fig 16). This is despite all of the above accomplishments of the Society, including changing policy this past year that will infuse more than $82 million into the specialty for the coming year. We must have participation of the 86% of members who have not supported the PAC. It is beneficial not only to or specialty but, ultimately, to our patients. We are all in this together, and together we will succeed! Our success is our patient’s success.

View larger version (17K): [in this window] [in a new window]   Fig 15. The 2006 election cycle political action committee (PAC) receipts through November 27, 2006, are noted for various groups. Note that the trial lawyers raised $6 million vs The Society of Thoracic Surgeons’ (STS) $377,000 (www.opensecrets.org). (AMA = American Medical Association.)

View larger version (20K): [in this window] [in a new window]   Fig 16. The 2006 breakdown of receipts of contributors (clear slice) vs noncontributors (grey slice) to the political action committee (PAC). Of major concern to The Society of Thoracic Surgeons is that only 14% of our members contribute to the PAC fund. This is not acceptable, and we must do better to have a major impact on health care policy. (STS Political Action Committee.)

Let me end this address as I did 11 years ago at the Southern Thoracic Surgical Association with the following: "Let us, the current generation of cardiothoracic surgeons, accept these challenges and successfully carry the proud and productive tradition of our specialty into the 21st Century."

Again, I thank you for the privilege of having served you and our patients this past year, and I know that we will collectively and unselfishly rise to the occasion and the common good and that our future will indeed be bright! May God bless all of you for the good work that you do.

	Acknowledgments

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 
I acknowledge and thank Ms Judi Arias, my Executive Assistant, for her tremendous effort in preparing this manuscript and the Power Point presentation.

	Footnotes

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 
Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29-31, 2007.

	References

Top Introduction Accomplishments During 2006-2007 Industry Relationships International Relationships Challenges and Opportunities Footnotes Acknowledgments References

 

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