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The Section of Cardiac Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
* Address correspondence to Dr Bove, Section of Cardiac Surgery, F7830 Mott Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109 (Email: elbove{at}umich.edu).
Presented as the President’s Invited Lecture at the Fifty-third Annual Meeting of the Southern Thoracic Surgery Association, Tucson, AZ, Nov 8–11, 2006.
Why a talk about excellence? As cardiothoracic surgeons, we are all accustomed to what it means to be "excellent." After all, thoracic surgery is the specialty that is always attracted the best into its midst: the brightest, hardest working, most innovative, and so forth. But it seems that today, more than ever, our specialty is being assaulted from all sides. Patients, payors, even our own colleagues are bombarding thoracic surgeons. Public demands are increasing, and public reporting of individual as well institutional outcome data is being demanded. Even more is on the way as we prepare for pay-for-performance guidelines. So it is perhaps fitting that now is the time for our specialty to define the appropriate metrics and redefine the characteristics that attracted us to this specialty to begin with.
According to Webster’s II New College Dictionary of the American Language [1], excellence is defined as "outstandingly good of its kind, of exceptional merit, virtue ... ." But just what are we to excel at? For most of us, our medical environment includes the hospital, medical school, and the clinic. For each of these areas, we face different demands and expectations (Fig 1). There are educational, clinical, investigational, and even fiscal benchmarks to achieve, often with conflicting incentives. To the classic triad of "teaching, research, and patient care" we must now add increasing financial limitations, what our payors regard as value. Furthermore, we are expected to achieve these goals not just for ourselves but also within the framework in which we exist. A so-called institutional perspective is often at odds with the day-to-day environment where we work. For example, today’s cardiac surgeons have very little in common with our colleagues in other surgical specialties but much more with those working in cardiology and radiology.
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Surgeons and airline pilots have been compared as two professions with much in common. Both disciplines are characterized by individuals who display leadership and have the ability to make decisions rapidly. Each requires communication and teamwork, and for each, the consequences of human error may be catastrophic. Although both of these areas have been said to be "hours of boredom punctuated by moments of sheer terror," surgeons would do well to learn from pilots. The airline industry has embraced the concept of the "near miss" as a learning experience, something the surgical profession has yet to do. As surgeons, we must change our culture. The captain of the ship mentality no longer applies. Like airline pilots, we must recognize human limitations and the impact of fatigue. We should develop checklists, contingency plans, and use all the resources available to us.
Excellence in surgery is rarely, if ever, accomplished by a single individual. Surgeons are not virtuosos performing in isolation. Just as in the understanding of human error, the opposite (excellence) is achieved within a system [3]. Perhaps one of the most noteworthy examples of this type of thinking was the recent inquiry in the United Kingdom into suboptimal results in congenital heart surgery experienced in a center that for too long turned a blind eye to the obvious. When warnings of a problem by nonsurgical staff went ignored, a complaint was lodged with the local lay press. A resultant uproar was soon created by the parents whose children had died and has led to profound changes in the practice of medicine throughout the United Kingdom. To quote the inquiry conclusions: "The inquiry team concluded that while the majority of children received satisfactory care, deficiencies were related to issues across the management and clinical spectrum rather than specifically related to the surgery." The effects on medical practice in the United Kingdom as a direct result of this inquiry include the requirement that all physicians must revalidate their right to practice every 5 years, the establishment of multiple additional regulatory bodies, and a change that training be determined by competency and not a fixed term. Furthermore, standards for patient information have been established, consent forms regulated, and individual surgeons must make their results available.
Faced with these issues, the thoracic surgery community has responded. Efforts are well underway to determine our own metrics of performance such that outcome reporting does not become a simple scorecard. National databases and risk adjustment are an important start. Although the development of an excellent surgical unit must measure up to certain norms, it also cannot be afraid to push the envelope. Furthermore, the measurement of outcomes should not be evaluated by an intervention or an operation but by the total survival of the disease or condition itself. The wine you drink is, to a large extent, determined by the grapes you pick. All too often, outcome reports in the literature fail to include those patients who never made it to the operating table.
Many factors may influence cardiothoracic surgery outcomes, including center volume, case mix and severity, support services such as cardiology, the intensive care unit, and anesthesia, as well as educational vs service demands. Mortality is perhaps the most often used arbiter of outcome quality. But for mortality rates to be useful, a procedure must have a relatively high mortality and be performed frequently. In fact, it is the poorest performers that may be overlooked. The problem of small sample size is often seen in the evaluation of outcomes in congenital heart surgery. Operations for congenital heart defects are infrequent, mortality rates are relatively low, and a failure to detect important differences between centers or individuals is more likely to occur (type 2 error). The minimum caseload needed to detect a mortality rate that is twice the benchmark is inversely related to the mortality rate [4]. For congenital heart disease, that equates to a caseload of 138 operations, an annual volume larger than many centers performing this type of surgery today. Other notable examples include esophageal surgery and aneurysm repair (Fig 2).
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The incentive to refuse treatment for high-risk patients has created a kind of spiritual crisis in the field of cardiac surgery. Heart surgeons, among the most highly trained and fearless of specialists, are shrinking from taking on the toughest cases because of statistics.
Excellence and leadership go hand-in-hand. It is incumbent on the leaders in thoracic surgery today to develop the best surgical units possible. This begins by recruiting the best talent. Pick the best, provide them opportunities to excel, and then get out of their way to allow these individuals to fulfill their potential. It is essential to be visible when things go bad and invisible when they go well. However, for our specialty to innovate, it is also important to foster an element of risk-taking, not fear of failure. Although measurements, quantification, and benchmarking are all valuable, "over caution" and paralysis induced by analysis can be stifling to innovation and progress.
There are many examples of new techniques that ultimately led to improved treatment paradigms, even in the face of heavy criticism at the time. One need only recall the history of primary closure for ventricular septal defects when pulmonary artery banding was the accepted norm or the advent of arterial repair for transposition when the Senning and Mustard operations were considered state of the art. It is important for every member of the team to have his or her niche, an area where they may assume responsibility and ownership. This inspires confidence and a feeling of self-control. In the words of the great racing champion, Mario Andretti, "if everything’s under control, you’re going too slow."
The traits that define what it takes to lead an excellent surgical unit may have changed in today’s environment, but certain values remain true. Be self-critical and never ask anyone to do anything you wouldn’t do yourself. Have a vision, aim high, and empower others. Inspire the faculty, arouse confidence, and provide constructive feedback. A good leader should shape the values of the group and establish a culture of behavior. It may also be appropriate to include those issues that seem to define our times more and more, including a horizontal administrative structure with representation at decision-making levels, eliminating internal competition, providing appropriate financial incentives, and rewarding the team approach. Finally and perhaps most importantly, don’t micromanage. You’ll get much more accomplished if you don’t care who gets the credit.
It might be appropriate to end this talk with the words of perhaps one of the greatest innovators in our field, C. Walton Lillehei, MD [6]:
Finally, in covering months and even years of progress in the short time available, I have undoubtedly created several misconceptions. First, I may have made the progress reported sound easy, effortless, and unobstructed. That most certainly was not the case. There were innumerable failures, disappointments, frustrations, and obstacles—nature’s as well as man’s. The only solution was a mixture of persistence and stubbornness.
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