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Ann Thorac Surg 1996;61:1045-1050
© 1996 The Society of Thoracic Surgeons
Department of Surgery, University of California, Davis, School of Medicine, Davis, California
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Introduction |
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 TopFootnotes Introduction References |
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Words cannot express my love for my family, and my gratitude to them for their unwavering indulgence of my commitment to thoracic surgery. My mother and father provided encouragement and opportunity. Joyce, my wife, has been my best friend and advisor for 33 years, and I still enjoy her company best of all. We are proud of each of our three children, Richard, Robert, and Nancy. There has been no greater joy than seeing each take his or her place as a responsible, ethical person with a commitment to excellence and drive to contribute to society. I am indebted to them for having kept me in the ``now generation.'' With us today is Richard's fiancée, Erin Borda, whom we are delighted to welcome.
My metamorphosis from medical student to thoracic surgeon began with William Elias Adams (Fig 1
), to whom I owe the beginning of my education in our specialty. He was a master surgeon, quiet and humble and a man of vision. To this day his residents refer to him fondly as Uncle Willie. Uncle Willie was a physiologist and inveterate clinical and laboratory research worker. Although he is perhaps most remembered for his contributions to esophageal surgery, his particular interest was in the prevention and treatment of lung dysfunction. He foresaw lung transplantation in 1958 when he assigned me to study the physiology of the reimplanted lung, long before it was a fashionable topic. He served with distinction as Chairman of the Board of Thoracic Surgery from 1955 to 1957 and as President of The American Association for Thoracic Surgery (AATS) from 1959 to 1960. To me and to my good friends, who were also University of Chicago students and residents, he was a great teacher, a role model, and friend.
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), who practiced medicine in Vienna before he had the courage to leave our roots behind to escape from Nazi terror and who died during voluntary service in the United States Army Medical Corps, I have kept close ties to Europe, and particularly to my treasured second family home, the Netherlands. Through the European connection I have been rewarded with special insights into thoracic surgery in Europe, where I believe elements of our future can be seen because single-payer universal-coverage health care is long established. Meanwhile, I have treasured the enormous privilege of working with giants in American thoracic surgery in the ABTS and our Residency Review Committee, where the viewpoints have largely been traditional and conservative. Now we need change in thoracic surgery.
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My audience today is truly expert, and so it is with humility that I want to make four points:
The past is prologue to the future, and selected history from the ABTS (the Board) is instructive [1]. The Board's first meeting as an affiliate of the ABS was on October 2, 1948, less than 48 years ago. Six years later, on May 26, 1954, the Board had its first discussion about the emergence of cardiac surgery. In 1956, the Board reaffirmed that there should be no special certification for cardiovascular surgery and that cardiovascular surgery should be included under thoracic surgery. The decision to include cardiovascular surgery in the examination was made. Four years later, in 1960, there was discussion with regard to changing the name of the Board to include cardiovascular surgery. The advice of the ABS was solicited. On October 22, 1962 the Board heard that the ABS had advised against a change in the name of the Board of Thoracic Surgery. Four years later, in 1966, there was discussion and dismissal of the idea that the prerequisite requirement of certification by the ABS might no longer be required. During the same year the Board considered and declined the possibility of issuing two types of certificates. The Board also considered and rejected changing the name to the American Board of Thoracic and Cardiovascular Surgery. The issue of name changes rested until January 1, 1971, when the Board of Thoracic Surgery officially became a primary board and was renamed the American Board of Thoracic Surgery.
In the decade of the 1970s, cardiac surgery strived for recognition. For example, the ABTS minutes of October 19, 1980, report that the AATS and the STS had suggested that the first step toward unification of cardiovascular and thoracic activities in the American College of Surgeons would be to change the name of the Advisory Council for Thoracic Surgery to its current name, the Advisory Council for Cardiothoracic Surgery. As we know, cardiac surgery thrived and emerged as a dominant force in our specialty.
In the decade of the 1980s GTS strived for recognition [2, 3]. The ABTS minutes of April 4, 1987, state that the Board's Issues Committee had discussed whether or not ABTS should continue to require certification by ABS, and whether or not GTS was to be considered the exclusive domain of the ABTS. The Board resolved that it would continue to investigate the advisability of allowing certification by ABTS without prior certification by the ABS.
This series of discussions that began 42 years ago by the Board is pertinent history because it is the background for the decisions thoracic surgery needs to make during today's cost-containment fervor, wherein there is such emphasis on generalism, efficiency, and cutback of funds. I believe we will soon be forced to choose either to continue with the prerequisite of ABS certification and to pay for thoracic surgery residents ourselves, or to develop shorter programs of thoracic surgery education with the end point of single board certification.
Contrary to the pessimism I hear expressed daily in locker rooms and in public, I am confident that the future of thoracic surgery is bright, exciting, and secure. Details of the future of CVS, GTS, and CHS as we know them today are not certain. We can no more predict what thoracic surgeons will need to know and do 50 years from now than John Alexander could have foreseen cardiac and pulmonary transplantation when he started the first formal thoracic surgery residency and wrote his classic text about the collapse therapy of tuberculosis. Therefore our best assurance of continued excellence and growth in thoracic surgery rests upon the quality and relevance of education.
Good education, if it is thorough and broad, teaches people how to learn and how to grow intellectually whatever may be the needs of the time. Well-educated professionals can be creative and they can maintain excellence under a variety of circumstances. I am convinced that the practice of thoracic surgery does not permit the time or opportunity to teach basic surgical skills and principles. Therefore, I insist that excellent schooling in general surgery, to a level of independent competence, is a requirement if thoracic surgeons are to remain ``surgeons and something more'' [4]. I am equally insistent that GTS and cardiac surgery supplement one another and that they need to remain together lest each be weakened through the loss of the other.
There is distressing worldwide evidence that cardiac surgery and GTS have drifted apart. In Canada, GTS and cardiac surgery are generally taught and practiced separately. In Europe, the situation is similar in many ways. Thanks to friends in thoracic surgery like Professor Hans Borst of Hannover, Professor Hans Huysmans of Leiden, and Dr Michael Lagaay of the Hague, who is a leader in Dutch general surgery, I can provide some of the evidence.
In Germany in 1986 to 1987, there were more than 13,000 major thoracic interventions done in general surgery departments [5]. How much more GTS was done by general surgeons is unclear because 70 departments that were queried did not respond. In 1989, 190 of 260 centers that proclaimed thoracic surgical work as part of their scope responded to a questionnaire [6]. As detailed in Table 1, 19 departments with more than 200 major GTS cases per year were responsible for 55.2% of the total interventions. It was not possible to be precise as to how much of the work was done by general surgeons, but it is clear that general surgeons did a substantial amount of thoracic surgery. According to Professor Dr Hasse, President of the German Society of General Thoracic Surgery, ``[In 1988] ...there were 38 units for cardiothoracic surgery in the Federal Republic of Germany West performing 32,800 cardiac operations with extracorporeal circulation. Twenty of them ...were also involved in general thoracic surgery. But obviously, the ever increasing demands of open heart surgery lead to a concentration on this topic. [Because of changes in Germany] from 1988 to 1994, ...one can be rather sure that general thoracic surgery has probably even lost importance.... Many general surgeons regard themselves particularly appropriate to participate in the field of general thoracic surgery because of their oncologic knowledge with other organ tumors...New rules ...this year [1995] are providing 3 year specialized practice in general thoracic surgery either in connection with general surgery or with cardiac surgery as basis. ...Certainly there will be considerable competition. ...'' (J. Hasse, President of the German Society of General Thoracic Surgery, personal communication, November 21, 1995).
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Well, so what? This is America and things are different. Let's see how different they may be, and let's keep in mind that our system of payment for medical services and our patterns of medical practice may well evolve rapidly toward those of Europe.
In the United States, some of my best previous general surgery residents are currently practicing thoracic surgery in sophisticated urban environments. For example, in a good 250-bed voluntary community hospital in the San Francisco area, a fine general surgeon who was my resident 26 years ago did 22 major pulmonary resections in 2 years, from July 1, 1993, through June 30, 1995. This was 15% of the total number of 143 major pulmonary resections in this hospital, wherein the staff includes 12 ABTS-certified surgeons, including 5 thoracic surgeons who emphasize cardiac surgery and center their practice almost exclusively at this hospital. One of the ABTS-certified surgeons in this group of 5 does almost all of the GTS. Is this reminiscent of your community?
In South Carolina, a rural state, a survey of Medicare, Medicaid, and commercial insurance carrier payments for ICD codes that applied to lung cancer treatment from October 1, 1993, to September 30, 1994, was done (C. E. Reed, Medical University of South Carolina, personal communication, July 18, 1995, and January 16, 1996). Early findings showed that only 30% of lobectomies and pneumonectomies were done by ABTS-certified surgeons; 70% of this thoracic surgery was done by ``other'' surgeons. Preliminary assessment suggests that thoracic surgeons did the work at less cost and with fewer complications than did the other surgeons (Table 2). More recent information that is still in early stages of analysis shows that 50% of pulmonary lobectomies and pneumonectomies was done by general surgeons during the 5-year period from 1990 to 1995. Most thoracic surgeons did more than 10 such operations per year, whereas 74% of the general surgeons did fewer than 10 procedures annually. There is indication that general surgeons under the age of 45 may have been the most active group doing GTS in South Carolina and that the role of general surgeons in thoracic surgery had increased with the passage of time.
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). The information for the previous 3 years is about the same as that for 1994 (Table 4). Medicare professional fee payments for lobectomies in 1994 were 73% to thoracic surgeons and 27% to other surgeons (Table 5). Thus, it is a reasonable estimate that nationwide, at least one third of GTS has been done by practitioners who are not ABTS certified.
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Before leaving the topic of the impact of managed care on thoracic surgery, let me tell you an experience I had just 2 weeks ago. A patient who needed a tracheal resection instead of the radiation therapy that his primary care physician had recommended consulted me at the suggestion of his radiation oncologist. His managed care insurance carrier refused to allow care in our hospital and directed the patient to its surgeon for this type of work. The managed care contract surgeon in this case was a surgical oncologist who was chosen by the plan in preference to a superb ABTS-certified surgeon who is in the audience today.
In short, community needs and standards have resulted in a large share of chest surgery being done by general surgeons. None of these general surgeons is eligible for membership in any of the thoracic surgery groups that we consider of high quality. None of these surgeons has had significant cardiac surgical experience, a background I consider essential for the maintenance and growth of GTS. For the general surgeons who practice GTS in the United States, the ABS certification examinations, local quality control assessments, and the courts are the standards by which their thoracic surgery work is evaluated. The existence of this gray market in thoracic surgery indicates that we who are in the mainstream of thoracic surgery have not met the needs of our communities.
How are the community needs for GTS being met? In 1984 the United States Air Force (USAF) established a 1-year program at the Veterans Administration Hospital in Biloxi, Mississippi, wherein selected, excellent graduates of USAF general surgical residencies are given training in GTS without cardiac surgery by a dedicated and effective ABTS-certified surgeon (L. J. Fontenelle, Medical Center, Biloxi, Mississippi, personal communication, June 1, 1995). This program has met the needs for GTS in USAF centers where no cardiac surgery is done. The director of the program writes, ``This fellowship has provided the necessary surgeons to perform specialized general thoracic surgery throughout the Air Force, allowing the cardiac surgeons to be placed in the current three cardiac medical centers. I am graduating my eleventh fellow from this program. This fellowship has provided the USAF with a specialized general surgeon who is credentialed by the Air Force to perform general thoracic surgery in [six] selected medical centers.'' The operative experience during the fellowship includes 100 to 130 thoracic procedures and 80 to 120 vascular surgical procedures along with 100 general surgical procedures. The USAF grants special certification in GTS upon successful completion of the program.
The USAF program has also met needs in the civilian community. To date, four graduates of this program have been separated from USAF, and all of them are successfully practicing GTS with general and vascular surgery in cities with populations of about 200,000. The concept that spurred the USAF program has spread because within recent months, as part of a widespread mailing, I received a letter from the University of Tennessee recruiting for a new 1-year GTS fellowship. Fortunately, this fellowship is for graduates of thoracic surgery residencies.
Although the story I have told might arouse fear about the future of GTS, it should recall the words of Franklin Delano Roosevelt when he said, ``The only thing we have to fear is fear itself.'' Let us therefore not spend our energies in consternation about change lest there will be too little strength left for adaptation.
What are the fundamentals of change? The foremost essential is to keep our focus on high quality. We must remain advocates for our patients and our specialty before we are advocates for ourselves. Second, we should acknowledge that we have not met the needs of our community in GTS. Thoracic surgeons who have chosen to emphasize CVS or CHS have demonstrated worldwide that they cannot give equal simultaneous emphasis to GTS. Third, we must be constructively proactive in practical and realistic ways.
Thus, what specific change is needed now? We need to respond immediately to the government's representation that the public is clamoring for more value than it has been getting in medical care. It will take time to dispel the myth that a major ingredient of cost containment is transfer of specialty care to generalists and to stop the current stampede of financial incentives for patients to give up free choice and access to specialists.
My proposal for change begins by accepting current wisdom that value can be measured by the formula:
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However, on behalf of our patients and high quality in thoracic surgery, I wish to modify the formula as follows:
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The constant ``k'' reflects the desires of our patients and our residents. Patients want their GTS near their homes, regardless of whether or not cardiac surgery is available. Many of the best general surgery residents do not have in-depth interest in cardiac surgery, but they want to practice GTS. Our choice is to continue to ignore this phenomenon with the result that GTS will increasingly be done by incompletely educated surgeons or to take the matter in hand and provide an alternative.
There is no greater aggregate of experience and wisdom in thoracic surgery than this audience. Thus, it is with humility and anticipation of counter proposals that I recommend the following:
The need for change has generated anxiety and confusion. The situation is reminiscent of a story I heard from the Honorable Manuel L. Real, United States District Court Judge in Los Angeles, during the recent swearing-in ceremony of my son Robert and his classmates into the Federal Bar. He told of a convoy of liberty ships during World War II when the threat of submarine attacks demanded secrecy. Time schedules and destinations were known only to the officers in the flagships. After a heavy storm, one of the ships found itself alone, not knowing where to go. In those days communications at sea were terse, and primarily by flashing lights. When the lone ship finally sighted another it flashed the message, ``Where am I?'' The other ship cautiously answered, ``Where are you going?'' and the first ship replied, ``I don't know.'' The second ship flashed, ``If you don't know where you're going why do you need to know where you are?''
We thoracic surgeons do know where we are, but we are anxious about where we are going and yet must prepare for the future. I am sure the future is bright, and if I had another chance to work in Uncle Willie's laboratory as a freshman at the University of Chicago School of Medicine, I would do so again.
This once in a lifetime opportunity to express my views to this expert audience is coming to an end. I hope I have made four points: (1) Thoracic surgery is surgery of the chest. Neither CVS, nor GTS, nor CHS can or should stand alone. (2) General thoracic surgery has slipped away from thoracic surgery worldwide, and this slippage has put patients at risk. (3) We urgently need a change in our educational programs so that they will be more consistent with community needs. (4) We need a proactive, cohesive thoracic surgery strategy for change, and our position needs to be in keeping with the fiscal and political realities of our time. Specifically, I have called for the further development of a risk-stratified system for measuring the value of GTS. I have urged that practitioners of GTS continue to be ABS and ABTS certified until better but shorter thoracic surgical education programs are available. You have heard my proposal for a three-track system of thoracic surgical education, and my belief that fully educated ABTS surgeons whose practice includes general surgery should be welcomed into our societies.
We are in the midst of rapid change. Let us lead the needed changes quickly and generously so that our patients will continue to benefit from the highest possible caliber of thoracic surgery.
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Footnotes |
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TopFootnotesIntroductionReferences |
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Address reprint requests to Dr Benfield, Division of Cardiothoracic Surgery, University of California, Davis, Medical Center, 4301 X St, Sacramento, CA 95817.
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References |
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TopFootnotesIntroductionReferences |
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This article has been cited by other articles:
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  J.Th.W. Hasse Perfection and compassion - essentials in cardio-thoracic surgery Eur. J. Cardiothorac. Surg., December 1, 2000; 18(6): 635 - 641. [Full Text] [PDF]
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J. R Benfield Surgical education in changing times Eur. J. Cardiothorac. Surg., September 1, 1999; 16(suppl_1): S6 - S10. [Full Text] [PDF]
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 D. J. Ullyot The Assault on Specialty Medicine and the Modern Surgeon J. Thorac. Cardiovasc. Surg., February 1, 1998; 115(2): 273 - 280. [Full Text] [PDF]
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 F. H. Edwards Analysis of Pulmonary Surgery Data: The Next Step Ann. Thorac. Surg., October 1, 1997; 64(4): 927 - 927. [Full Text]
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F. H. Edwards and J. I. Miller Jr A National Database for Pulmonary Surgery Ann. Thorac. Surg., February 1, 1997; 63(2): 321 - 321. [Full Text]
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