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Ann Thorac Surg 2000;69:1653-1654
© 2000 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, St. Louis University Health Sciences Center, St. Louis, Missouri, USA
Address reprint requests to Dr Naunheim, Division of Cardiothoracic Surgery, St. Louis University Health Sciences Center, 3635 Vista Ave at Grand Blvd, St. Louis, MO 63100-0250
e-mail: naunheim{at}slu.edu
The article by Petsikas and colleagues in this issue of The Annals [1] reviews one institution’s experience with postoperative surveillance in lung cancer patients who have undergone resection. The authors compare and contrast the clinical results and cost of follow-up by thoracic surgeons and family practitioners. They suggest that it may not matter who provides routine follow-up in resected patients; most who recur are symptomatic, and curative reoperation is exceedingly rare. It is their contention that family practitioners could provide follow-up care at significantly lower cost with no negative effect on clinical outcome.
This article is likely to irk some experienced thoracic surgeons who are dedicated to their patient’s well-being and provide regular postresection follow-up. Many such clinicians feel that not only is a thoracic surgeon best able to provide optimal long-term follow-up from the medical perspective, but that he/she also develops a special rapport with patients and is better able to provide reassurance and comfort.
This issue has been dealt with before in an editorial by Hiebert in this journal in 1995 [2]. Dr Hiebert pointed out that the delivery of follow-up care by a thoracic surgeon provided an educational experience for the surgeon, a potential for improved clinical outcome, and emotional benefit for the patient. The educational benefit came as a result of the surgeon’s opportunity to follow the natural history of the disease and to observe the effect of surgery on the patient, thus, potentially allowing the surgeon to modify his/her techniques for the better. While there is no question that postoperative follow-up within the first weeks to months does provide such opportunities, it is likely that long-term follow-up for lung cancer patients will yield diminishing educational returns decade after decade.
As to the potential medical benefit of routine postoperative follow-up by the thoracic surgeon, neither this paper nor the existing literature demonstrate improved outcome from surveillance irrespective of the type of physician following the patient. The optimal postresection surveillance is unknown, and practices vary widely even within the thoracic surgical community [3]. There are no objective data to substantiate the notion that an experienced thoracic surgeon will be more sensitive to the signs and symptoms of recurrence and make the diagnosis at an early stage, thus allowing for cure. Once recurrent cancer or second primary lesions become symptomatic or cause physical findings, it is curable only in anecdotal cases. It is the asymptomatic lesion present on chest roentgenogram or computed tomographic (CT) scans that yields a significant chance for curative intervention. These lesions are just as likely to be detected by an "average" radiologist or family practitioner, as by an "average" thoracic surgeon. There is little question that a family practitioner or other nonsurgical specialist can obtain an adequate history, do a satisfactory exam, and evaluate the same chest roentgenogram all at a lower opportunity cost than the highly trained, relatively costly thoracic surgeon. Unfortunately, economic resources in medicine are currently limited and will likely decrease further in the future. It makes sense to consider the more cost-effective solution of using nonsurgeons to provide follow-up care. Truly significant improvements in early detection and treatment of recurrent or second primary cancer will likely come not from more highly specialized physician involvement, but rather due to technological advances such as low-dose spiral computed tomography or monoclonal testing for sputum cytology [4, 5]. Identifying a testing strategy that benefits patient outcome in a cost-effective fashion should be our primary goal in the arena of postoperative surveillance.
Perhaps the more upsetting issue is the sense of patient "abandonment" to which Hiebert has alluded. The lack of opportunity for thoracic surgeons to interact with the patients and provide continued comfort or counsel will be interpreted as symptomatic of the continuing erosion of the physician-patient relationship. However, we in the thoracic surgical community must not delude ourselves. In these days of shrinking reimbursement for hospitals and physicians, everyone in health care is being pressured to increase "productivity." For the thoracic surgeon, this means an increase in the volume of clinical activity leading to longer periods of time in the operating room and shorter "face-to-face" interactions with patients. Because of these increasing time demands, it is unlikely that a busy thoracic surgeon will expend more time, have more empathy, or demonstrate more compassion than a family physician or other nonspecialist colleague. Most of the thoracic surgical community lack both the time and temperament to provide optimal emotional support for lung cancer patients during long-term follow-up.
There continues to be evolution in the health care market. While there is an increasing demand for more advanced technology and higher volumes of care, the resources available to provide such care are not increasing proportionately. These forces threaten to further limit access to health care in this country at a time when a significant percentage of the population lacks health care coverage. Any actions that improve the delivery of health care or make it more cost effective can help alleviate this problem.
There has also been an evolution in cardiothoracic surgical specialists over the last several decades. Most thoracic surgeons nearing or just past retirement began their surgical careers removing gallbladders, colons, and stomachs. During their training, few would have believed that at the end of their career they would be performing minimally invasive valve replacement or lung volume reduction surgery. In the 1960s, a surgeon could be an acceptable "all-around" doctor with a good foundation of knowledge in all specialties. The explosion of medical knowledge in the last 40 years has now made this a patently impossible goal. The role of the CT surgeon has become increasingly more specialized and limited. Although many surgeons might miss the past and yearn for the time when they were truly a "general surgeon," few would argue that a return to the "good old days" would be beneficial for health care of the community at large. Unfortunately, less patient interaction may also yield fewer personal rewards. Basking in the gratitude of a long-term survivor is an ego-enhancing experience, and few of us wish to become merely surgical technicians residing in the operative theater.
We must realize that over the last few decades our role has changed and, as Petsikas and colleagues suggest, the continuing evolution in health care may force us out of the follow-up clinic. However, these authors do not advocate the removal of a caring, compassionate physician from the equation. Rather, they suggest a substitution to make the process more efficient and less costly without decreasing the quality of care provided. Few in the medical profession are happy with the current trends in health care, and many are working to reverse the continued diminution of resources that has resulted in greater pressure for individual physician productivity (increased patient loads). Many of us miss the opportunity to interact more fully with postoperative patients and establish a rapport through the time-honored tradition of obtaining a history and performing a physical exam. This "laying on of the hands" is a comforting ritual for patient and physician alike. There is, however, no evidence to suggest that "medical" hands will be any less caring or beneficial than those of the surgeon, and they will almost certainly be more cost effective. We must strive to husband our time and resources, yet still provide care without compromising patient outcome. It seems probable that postoperative surveillance can be effectively and economically provided by nonthoracic surgical physicians as long as they are appropriately educated regarding specific clinical issues. Further investigation will be required to assure this is a safe practice. For surgeons, this may lead to less involvement in long-term care. The times are changing and we must change with them.
References
Related Article
This article has been cited by other articles:
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  J. R. Benfield Systematic Postoperative Radiologic Follow-up in Patients With Non-Small Cell Lung Cancer for Detecting Second Primary Lung Cancer in Stage IA--Invited Critique Arch Surg, August 1, 2002; 137(8): 940 - 940. [Full Text] [PDF]
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