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Click here to read this article as a CME activity
Department of Surgery, University of Washington, Seattle, Washington
Accepted for publication December 1, 2008.
* Address correspondence to Dr Wood, University of Washington, Department of Surgery/Division of Cardiothoracic Surgery, Box 356310, 1959 NE Pacific St, Seattle, WA 98195 (Email: dewood{at}u.washington.edu).
Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009. Winner of the J. Maxwell Chamberlain Memorial Award for General Thoracic Surgery.
| GENERAL THORACIC SURGERY:
The Annals of Thoracic Surgery CME Program is located online at http://cme.ctsnetjournals.org. To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal.
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Abstract |
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Methods: A cohort study (1992 through 2002, follow-up through 2005) was conducted using Surveillance, Epidemiology, and End-Results-Medicare data. The American Board of Thoracic Surgery Diplomates list was used to differentiate board-certified thoracic surgeons from general surgeons (GS). Board-certified thoracic surgeons were designated as cardiothoracic surgeons (CTS) if they performed cardiac procedures and as general thoracic surgeons (GTS) if they did not.
Results: Among 19,745 patients, 32% were cared for by GTS, 45% by CTS, and 24% by GS. Patient age, comorbidity index, and resection type did not vary by surgeon specialty (all p > 0.10). Compared with GS and CTS, GTS more frequently used positron emission tomography (36% versus 26% versus 26%, respectively; p = 0.005) and lymphadenectomy (33% versus 22% versus 11%, respectively; p < 0.001). After adjustment for patient, disease, and management characteristics, hospital teaching status, and surgeon and hospital volume, patients treated by GTS had an 11% lower hazard of death compared with those who underwent resection by GS (hazard ratio, 0.89; 99% confidence interval, 0.82 to 0.97). The risks of death did not vary significantly between CTS and GS (hazard ratio, 0.94; 99% confidence interval, 0.88 to 1.01) or GTS and CTS (hazard ratio, 0.94; 99% confidence interval, 0.87 to 1.03).
Conclusions: Lung cancer patients treated by GTS had higher long-term survival rates than those treated by GS. General thoracic surgeons performed preoperative and intraoperative staging more often than GS or CTS.
Lung cancer is responsible for more deaths than prostate, breast, and colorectal cancer combined [1]. Pulmonary resection provides optimal therapy with curative intent for those with early stage disease and select patients with locally advanced lung cancer. Lung resections are performed by surgeons with and without board certification in thoracic surgery. Two previous studies have shown that board certification is associated with lower operative mortality rates—a marker of surgical safety [2, 3]. Five-year survival rates—a marker of treatment effectiveness—have not been described among patients under the care of different types of surgeons. It has been suggested, although not demonstrated empirically, that long-term outcomes might vary by surgeon type because of differential use of processes of care, such as preoperative staging, extent of resection, and use of multimodality treatment [4].
Using the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database, we examined variation in the use of processes of care and long-term survival by surgeon specialty among lung cancer patients. We hypothesized that patients under the care of board-certified general thoracic surgeons (GTS) would have higher survival rates than those under the care of general surgeons (GS), and that differential use of processes of care might explain any observed variation in outcome.
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Among 221,208 patients diagnosed with lung cancer, exclusions were made as follows: diagnosis at death or autopsy (n = 5,109), unoperated patients (n = 188,469), age younger than 66 years (n = 2,376), diagnosis of another primary malignancy 3 months before and 6 months after lung cancer diagnosis (n = 1,445), part A or B coverage only or concurrent health maintenance organization enrollment (n = 2,208), patients who could not be linked to hospital or surgeon files (n = 1,816), and those with histologic classification inconsistent with lung cancer (n = 40). These exclusions were necessary to ensure the completeness and accuracy of using claims data for research purposes as discussed previously [6].
Three groups of patients were defined on the basis of whether their operation was performed by a GS, cardiothoracic surgeon (CTS), or GTS. Surgeons who could not be matched to the American Board of Thoracic Surgery list were considered GS. Board-certified thoracic surgeons who performed at least one coronary artery bypass graft or valve procedure among any patient in this cohort between 1992 and 2002 were classified as CTS. All other board-certified thoracic surgeons were considered to be GTS.
The primary outcome was overall survival. Death attributable to any cause was ascertained using the Medicare Enrollment Database and follow-up was available through 2005. Secondary end points included lung cancer cause-specific survival, operative mortality, tracheostomy or reoperation within 90 days of resection, prolonged length of stay greater than 14 days (PLOS), discharge to an institutional care facility, and readmission within 30 days of index hospitalization. Cause-specific death information was only available through the SEER registry with limited follow-up through 2004. Tracheostomy and reoperation were defined by their Healthcare Common Procedure Coding System billing codes (Appendix). Health-care utilization was ascertained using the Medicare Provider Analysis and Review file.
Processes of care included the use of staging modalities, extent of resection, cardiac procedures, and multimodality therapy and were ascertained using billing codes within the Carrier and Outpatient claims files (Appendix).
Patient-level covariates were mostly available through the SEER registry [7]. The Klabunde-modified Charlson comorbidity index was calculated using claims from the Carrier and Outpatient files in the year before diagnosis [8]. Hospital-level covariates were ascertained using the Medicare Healthcare Cost Report and Provider of Service survey. Teaching status was based on affiliation with a medical school or a resident-to-bed ratio of greater than 0.25 [9]. Hospital and surgeon annual average volumes were calculated among the SEER-Medicare cohort [10].
All statistical analyses were performed using STATA (Special Edition 9.2; Statacorp, College Station, TX). Differences in categorical variables were tested using the 
2 test, and differences in means and medians were tested using analysis of variance and nonparametric equality-of-medians test, respectively. Survival estimates were obtained using Kaplan–Meier methods. Survival time was defined as the interval between date of resection and date of death or censoring. Because of the competing risk of death attributable to other causes the cumulative incidence of death from lung cancer was used to estimate cause-specific survival [11]. For similar reasons, the cumulative incidences of tracheostomy, reoperation, and readmission were estimated while censoring for deaths occurring within the period of outcome ascertainment (ie, 90 days for tracheostomy). Cox proportional hazards models were used to evaluate the unadjusted and adjusted relationship between surgeon specialty and overall and cause-specific survival, tracheostomy, reoperation, and readmission. Schoenfeld residuals were used to examine the proportional hazards assumption and extended (stratified) Cox models were fitted if this assumption was not met. Logistic regression was used to evaluate the relationship between surgeon specialty and processes of care and unadjusted and adjusted early deaths, PLOS, and discharges to ICFs. All regression models adjusted for clustering at the hospital level. Because 20% of patients had at least one missing covariate, all multivariate analyses were repeated using multivariate imputation by chained equations [12]. Two-sided probability values less than 1% were considered significant.
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Differences in patient selection and therapeutic decision-making as a result of more extensive cancer staging might explain some differences in patient outcomes by surgeon specialty. Accurate staging is believed to result in more appropriate use of cancer therapy and therefore better outcomes. The use of positron emission tomography is associated with greater diagnostic accuracy [13, 14], and the effect of intraoperative mediastinal node dissection on survival is currently being evaluated by an American College of Surgeons Oncology Group trial [15]. In the current study, GTS more frequently used positron emission tomography and performed lymphadenectomy.
Variation in outcomes by surgeon may also be related to aspects of patient selection and clinical decision-making not measured in our study. For instance, forced expiratory volume, performance status, and extent of resection are associated with survival [16–18] and may vary across patients cared for by different surgeons. Predicted postoperative forced expiratory volume may be used to determine eligibility for resection [19], and some believe that select patients with limited pulmonary function may benefit from sublobar resections [20]. The role of performance status in determining eligibility for resection is unclear, but providers tend to underestimate performance status (relative to patient self-report) when measured by the Eastern Cooperative Oncology Group scale [18]. It is unknown whether different types of surgeons assess physiologic eligibility for resection differently, and we were unable to evaluate this hypothesis further because the SEER-Medicare database does not record these variables. Although the extent of resection did not vary by surgeon specialty, the appropriateness of resection could not be determined without knowledge of other clinical factors.
Other explanations for differences in patient outcomes by surgeon specialty include stage migration, lead-time bias, and confounding. Stage migration—also known as the Will-Rogers phenomenon—describes a situation in which more accurate stage classification leads to better observed survival rates [21]. Because GTS used staging modalities more often, it is possible that better survival differences as compared with other surgeons' patients are explained in part by stage migration. Lead-time bias occurs when the onset of observation is different for different groups of patients. The average interval between presentation and therapy is approximately 90 days [22]. If GTS work in systems of care that more expeditiously work up, refer, and treat patients, then it is possible that our results suffer from lead-time bias because we measured survival time based on the date of resection. Nevertheless, if this is the reason for survival differences, then our results would still be consistent with the notion that GTS (and the systems in which they work) provide more expeditious and higher quality care than other surgeons. Finally, as discussed earlier, an inability to measure variables such as forced expiratory volume, performance status, and the severity of comorbidities might have resulted in confounding bias. If so, our results might be explained by "sicker" patients being preferentially referred to GS. Yet, it is more likely that specialists care for sicker patients. If true, then the association between surgeon specialty and long-term outcomes might, in fact, be underestimated.
Several possibilities may explain variability in practice patterns across surgeons. Like other fields of surgery, there is little level 1 evidence to support the use of specific processes of care in the operative management of lung cancer patients. As a result, practice patterns more likely depend on knowledge, experience, attitudes, and beliefs. Surgeons may differ in this regard based on presence or absence of specialty training in cardiothoracic surgery, a broad scope of practice versus a narrower scope of subspecialty practice, participation in continuing education activities specific to thoracic surgery, and networking within groups of similarly trained and practicing surgeons. Alternatively, practice patterns may be influenced by factors unrelated to surgeons—such as barriers to accessing care. For instance, patients under the care of GS and CTS more commonly lived in rural areas. It is possible that technologies such as positron emission tomography are less likely to be available to these patients and surgeons. However, limited access to care is unlikely to fully explain differences in care patterns because procedures such as mediastinoscopy and lymphadenectomy are dependent on the surgeon rather than the system in which they work.
Although we found no evidence of variation in adverse events by surgeon specialty, we did observe decreasing trends in operative mortality, tracheostomy, and PLOS as a function of time, but only among patients cared for by GTS. Pulmonary complications are the leading cause of early death after lung resection [23, 24], and they were recently shown to be the most common reason for PLOS [25]. Declining trends in these end points with time suggest that GTS might have increasingly adopted processes of care that mitigate the risk of pulmonary complications after lung resection. Examples of processes of care include the use of diffusion-limited capacity of carbon monoxide for risk stratification and patient selection [26], a video-assisted thoracoscopic surgery approach to pulmonary resection [27], thoracic epidural catheters [28], and preoperative pulmonary rehabilitation [29].
This investigation had limitations. There is no standard definition for a GTS. Our use of a major cardiac surgery procedure to define CTS with a mixed cardiac and general thoracic practice was purposefully conservative in an effort to identify dedicated GTS. Groups such as the GTSC recognize GTS as those with a noncardiac thoracic surgery caseload of at least 50% [30]. When using GTSC membership as the criteria for defining GTS, survival differences between surgeons were even more dramatic, suggesting that our a priori definition for surgeon specialty was at least conservative. However, using a professional society membership may not be generalizable if there are subsets of GTS who do not seek membership in an organization such as the GTSC. Moreover, although American Board of Thoracic Surgery certification is the best available surrogate for specialty training in cardiothoracic surgery in the United States, there are likely to be foreign-trained CTS performing lung cancer resections in the United States who do not have American Board of Thoracic Surgery certification and would have been categorized as GS in our analysis. One would expect this misclassification to elevate the outcomes of nonspecialty surgeons in this study and is another reason why the difference between GS and GTS may actually be underestimated in our analysis. We made no attempt to differentiate outcomes between academic and nonacademic GTS. Although a higher proportion of teaching institution affiliation was observed in the GTS group, the final analysis adjusted for hospital teaching status to allow for comparisons of outcomes that were independent of academic status.
Our findings may not be generalizable because of our exclusion criteria, particularly limiting the study to Medicare beneficiaries. Given that the median age of operated on lung cancer patients is 67 years [31] and that Medicare provides coverage for 97% of elderly patients, our findings are at least relevant to a majority of patients. The SEER-Medicare provider volume insufficiently captures true provider volume, although the resulting misclassification tends to bias the volume-outcome relationship toward the null hypothesis [10]. Covariate data may not have been missing completely at random, in which case both our case-complete and imputed data analyses may have been biased. Analyses of cause-specific death data may not be valid because cause of death information was based on death-certificate data [7]. Finally, these data span an 11-year period and are at least 6 years old. The SEER-Medicare database was the most contemporaneous database available to test our hypothesis, and because the primary end point was long-term survival, the data were necessarily outdated. Because the fields of thoracic oncology and surgery have changed rapidly during this time, and because specialists may adopt changes earlier than generalists, our data may not provide the most contemporaneous comparison of outcomes across surgeons.
Limitations notwithstanding, our results are relevant to debates about the best method of improving the quality of thoracic surgical care in the United States. One option might be to encourage referral of potentially resectable lung cancer patients to GTS. Any such policy will have to address potential barriers to accessing care, particularly among low-income patients and those who live in rural areas. Additionally, any such policy would have to ensure an adequate workforce of GTS. Although our results show that patients are increasingly being referred to CTS rather than GS over time, GTS cared for a similar proportion of patients as a function of time, and the distribution of surgeons has not changed. Attempting to improve outcomes by preferential referral to GTS without addressing infrastructure and workforce concerns might lead to the unintended consequence of depriving a large majority of patients care for an otherwise uniformly fatal disease. An alternative policy might link reimbursement to performance as a means of encouraging best practices among all types of surgeons practicing in a variety of settings. Performance would have to be linked to process measures known to affect long-term outcomes because measuring long-term survival is not feasible outside a research setting. Another measure of performance with a powerful impact on outcomes is participation in a large national or regional database with inclusion of all patients and frequent provider feedback with comparisons to peer norms. For instance, on August 5, 2008, the National Quality Forum endorsed participation in a systematic national database for general thoracic surgery [32]. However, any such pay-for-performance intervention would have to provide the resources to fund database efforts or other processes of care found to be beneficial to lung cancer patients, rather then simply instituting an unfunded mandate. In other settings, quality improvement initiatives have been speculated to be linked to cost-savings, and thus the expense of such interventions would be expected to be largely or completely offset—a bonus beyond the intended benefit of improved long-term outcomes for lung cancer patients [33, 34]. Finally, while quality improvement policies are debated, general and cardiothoracic residency programs might wish to increase exposure to the general thoracic surgical service with an eye toward teaching important processes of care and clinical situations that require referral to a dedicated thoracic surgical oncologist.
In conclusion, patients under the care of GTS had higher survival rates than those under the care of GS. General thoracic surgeons performed more extensive preoperative and intraoperative cancer staging compared with CTS and GS. A better understanding of the reasons underlying these differences will likely help develop interventions aimed at mitigating unnecessary variation in care and outcomes. Patients, surgeons, physicians, and other stakeholders should recognize the potential risks and benefits associated with regionalization of care, pay-for-performance, and other policy-level interventions aimed at improving the quality of thoracic surgical care.
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HCPCS = Healthcare Common Procedural Coding System; ICD-9 = International Classification of Diseases, 9th ed; PET = positron emission tomography; RCC = Revenue Center Code.
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In 2005 at the STS meeting in Tampa, Dr Alex Little presented "Patterns of Surgical Care of Lung Cancer Patients." In 2001, only 27% of patients underwent mediastinoscopy, with about half not submitting any lymph node tissue to pathology, PET scans were obtained in 26%, and 42% of patients had no mediastinal staging at the time of operation. In 2007, at the AATS annual meeting, Dr Daniel Boffa reported on the STS general thoracic database spanning from 1999 to 2006. Thankfully, the rate of mediastinal lymph node evaluation was 65%.
This study reported that lymphadenectomy was only used in 33% of patients by general thoracic surgeons. Now, granted, that is better than 11% by general surgeons, but, folks, we have a problem. This disturbing figure was not compensated by use of PET, 36%, or mediastinoscopy, 18%.
Two conclusions: The word needs to get out to the public that lung cancer should be treated by proper surgeons; second, we need to continue to do better staging in our patients, both clinically, to offer them the correct treatment, and pathologically to ascertain need for adjuvant therapy and to counsel patients about their prognosis. I have a couple of questions.
Did the rate of lymphadenectomy recorded include node sampling? Please tell us that more than one-third of the patients had some attempt at identifying pathologic N2 disease?
Second, the ACGME 2006–2007 residency case data reports that the national average of lung cancer resections done by general surgical residents during five years of training is six. Do you feel that we have now accumulated enough evidence to publicly advocate that all lung cancer patients should see a board-certified CT surgeon or equivalent?
Thank you. I very much enjoyed your paper.
DR FARJAH: Thank you, Dr Reed, for reviewing our work and your comments. Your first question was about whether our rate of lymphadenectomy included lymph node sampling, and the answer is that it might not have. Lymphadenectomy rates were based on a CPT code for lymphadenectomy. There is no CPT code for lymph node sampling. So I would agree with you that intraoperative N2 staging is important and that these low rates are concerning, especially among specialists. Until it can be verified that rates of intraoperative N2 staging are higher, I think that your concern is very appropriate and I absolutely agree with it.
Your second question was about regionalization essentially. I think from the perspective of thoracic surgeons, the most likely policy conclusion that one would reach from this data is regionalization, and that very well may be the answer. Viewed from the perspective of a policy maker, however, there is always the concern about unintended consequences of short-sighted policies. Though I think it is true of any policy, for the purposes of discussion, we can use regionalization and our data as an example. If there is a strict policy of mandatory regionalization that does not address transportation and housing of patients and families, then what is going to happen to those patients? These are patients that may have received suboptimal care in the past but may subsequently not be able to receive any care, and again, we are talking about lung cancer, a uniformly fatal disease when untreated.
Let us say the policy addresses that issue but patients refuse to travel. How will that policy be helpful if a small fraction of patients are no longer getting any therapy for lung cancer? And let us say that patients are willing to travel and that the infrastructure issues are addressed, are there enough general thoracic surgeons to accommodate the increase in volume? If not, will there be delays in care, and if there are delays in care, will that adversely affect outcomes? I do not know the answers to these questions and one could play out these adverse scenarios with any policy.
So I think that our study answers a question that was posed a decade ago, and in the process of doing so it also raises many other questions. I think the things that can be done right now include, one, participation in either a national or a regional quality improvement initiative. The STS general thoracic database is one example of such an initiative, and NSQIP is another. The second thing that can be done is this information can be disseminated among surgical colleagues, nonsurgical colleagues, the public, your patients. There is no reason why this information should not be disseminated and there are no reasons why there cannot be passionate debates about the right answers.
DR RICHARD J. SHEMIN (Los Angeles, CA): I rise not to question the added quality that a general thoracic surgeon brings to the care of patients with lung cancer.
In the year 2000, the STS/AATS Taskforce on Practice and Access published a study reporting that about 70% of adult cardiac surgeons perform general thoracic surgery in their practice. So one question is if Board certified Thoracic Surgeons who primarily identify themselves as adult cardiac surgeons provide the same quality as our general thoracic colleagues?
My second point is that the Taskforce worked with David Wenberg at Dartmouth. We studied regional variations in pulmonary resections and what type of surgeon performed the pulmonary resection. We found a significant misdistribution of general thoracic surgeons around the country. They were mostly located in large metropolitan areas. When we looked at general surgeons performing general thoracic procedures, they were in areas where there was poor access to a board-certified thoracic surgical specialist. The general surgeons, in general, performed less pulmonary resections than general thoracic surgeons. Thus, in part we are dealing with an access issue.
You have partially addressed this issue with your comments on regionalization. However, the fact is unless there is an improved distribution of thoracic surgeons, non-thoracic surgeons will continue to be called upon to perform these procedures. Patients will not travel to regional centers.
I am interested in your comments.
DR FARJAH: Thank you for the questions, Dr Shemin. We found no evidence of a difference between cardiothoracic surgeons and general thoracic surgeons. So there is no evidence to suggest that cardiothoracic surgeons should not do these operations.
Your second question was about the maldistribution of specialists, and we confirm your findings. In one of the slides I showed, roughly 20% of general surgery patients lived in urban or rural areas as opposed to 7% of general thoracic surgical patients, and there were geographic differences as well. So I agree with you, and I think your point speaks to the unintended consequences of regionalization. These issues have to be sorted out before a policy is instituted, because a worst case scenario would be for patients who previously received suboptimal care to subsequently receive no care at all for a uniformly fatal disease.
DR JOHN R. BENFIELD (Los Angeles, CA): In 1995, when I had the privilege of giving the presidential address to The STS, I addressed the issue that you have just brought to our attention. One of the few data points we had was Carolyn Reed's information from rural areas of the Southeast United States. Thanks to Professor Joachim Hasse of Freiburg, Germany, and others in Europe, we knew that about 80% of general thoracic surgery in Europe was being done by general surgeons. In Northern California, where I was working in 1995, much (perhaps most) of general thoracic surgery was being done by general surgeons.
My address was entitled "Metamorphosis" (Ann Thorac Surg 1996;61:1045–50). My proposal was controversial, and it generated no traction. This was probably because organized thoracic surgery did not fully accept the reality of so much thoracic surgery being done by general surgeons. In 2008 this phenomenon is still happening. Many patients are not getting the best available care that they need and deserve.
I take this opportunity to reiterate my proposal of 1995. I suggest that The STS grapple with this issue constructively and aggressively. We should offer to evaluate the work of general surgeons who are doing thoracic surgery, seeking to identify those whose current work is acceptable, despite their lack of background and training that meets our standards. Those general surgeons who are doing acceptable thoracic surgery, and know their limitations, should then be taken into our fold. They could then come and participate in our continuing education meetings. We should suggest a minimum of continuing education in thoracic surgery. We should create a grandfather clause, with a reasonable end point. We should urge CMS and other insurance carriers thereafter no longer to pay for thoracic surgery done by incompletely educated surgeons. Thereby we would elevate the standard of thoracic surgery in the U.S. I would appreciate your comments.
DR FARJAH: Given the complexity of the situation, all options should be on the table, and your suggestion is certainly a legitimate option. It would depend, however, on the willingness of general surgeons to actually undergo continued training and education, and the willingness of general thoracic surgeons to provide that sort of oversight and guidance. Assuming both of these factors being true, your suggestion might be a better option than regionalization. But, again, we do not have enough information to address these assumptions at this time.
DR TARA KARAMLOU (Ann Arbor, MI): Nice talk. It parallels some of our own work in congenital heart surgery. I wonder whether, however, some of your comparisons are biased by the disparate environments that general surgeons may operate in as opposed to specialists, board-certified general thoracic surgeons. So I wonder if you plan to extend your study to look at a hospital-based analysis to see whether or not surgeon specialty and the findings of your present paper are influenced by the practice setting in which the surgeon treats these patients?
DR FARJAH: Thank you. I agree with you that some of the association between surgeon specialty and outcomes is explained by hospital-level characteristics, and our data, to some extent, describe this relationship with regards to hospital volume and teaching status. When we adjusted for these factors, the association between surgeon specialty and outcomes was attenuated, though it persisted. As far as I know, the only structural measure that has been linked to long-term survival is hospital volume. In order for other structures measures to be a confounding factor, they would have to be related to both the exposure and the outcome. So a priori evidence exists only for hospital volume, which we adjusted for that variable. It very well may be that other hospital-level factors are important, too. Your point is well taken, however, there may be other unmeasured structural factors that are important.
DR JEAN DESLAURIERS (Ile d'Orlean, Prince Edward Island, Canada): I think that this paper is important because it suggests that managing lung cancer is no longer a matter of operation versus no operation but that it requires multimodality therapies that should be individualized for each patient based on stage and histopathology of their disease. Although the data presented this morning does not correlate multimodality approaches and board certification, I suspect that most well-trained thoracic surgeons know more and use more adequately induction treatments and post-operative adjuvant therapies than do non-certified surgeons and this is most likely the reason why they have better survival results.
DR FARJAH: Thank you. I do not think there is anyone in the audience that would disagree with you about the multidisciplinary nature of thoracic oncologic surgery. Unfortunately, this data set does not allow us to measure a multidisciplinary approach to patient care.
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Farhood Farjah was supported by a Cancer Epidemiology and Biostatistics Training Grant (T32 CA09168-30) and National Research Service Award (F32 CA130434-01) from the National Cancer Institute. The interpretation and reporting of these data are the sole responsibility of the authors. The views expressed in this article do not necessarily represent the official views of the National Cancer Institute, National Institutes of Health, Centers for Medicare & Medicaid Services, American Board of Thoracic Surgery, or the University of Washington.
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This article has been cited by other articles:
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  D. E. Wood and F. Farjah Surgeon specialty is associated with better outcomes: the facts speak for themselves. Ann. Thorac. Surg., November 1, 2009; 88(5): 1393 - 1395. [Full Text] [PDF]
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