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Ann Thorac Surg 2004;78:391-398
© 2004 The Society of Thoracic Surgeons
a Carlyle Fraser Heart Center, Emory University School of Medicine, Atlanta, Georgia, USA
* Address reprint requests to Dr Guyton, Cardiothoracic Surgery, Suite A2223, 1365 Clifton Rd NE, Atlanta, GA 30322, USA
e-mail: robert_guyton{at}emoryhealthcare.org
Presented at the Fortieth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 26–28, 2004.
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Introduction |
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 Top Introduction The transformation of the...Innovation in clinical skillsQuality in health carePolitical engagementConclusion—our motivationReferences |
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| Dr Guyton discloses that he has a financial relationship with Medtronic, Inc.
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I divide my effort into three parts. First, where are we now? I will describe the transformation of The Society of Thoracic Surgeons (STS). Second, where are we going? I will discuss three facets of our future: innovation in our clinical skills, quality in health care, and political engagement. And third, why must we move forward?
Last year Dr William Baumgartner spoke of his optimism regarding our specialty. I believe that optimism is justified, but for me, that has not always been the case. In 1997 I was just beginning my term as Treasurer of your organization. I was paralyzed with a gut-wrenching angst about the future of our specialty. Eleven months away was a 40% reduction in Medicare reimbursement for cardiac surgery. Doctor Robert Repogle brought us the message: "Armageddon is here!"
I remember reading Matthew Arnold's "Dover Beach" and thinking, "This is where we are!":
For the world, which seems
To lie before us like a land of dreams,
So various, so beautiful, so new,
Hath really neither joy, nor love, nor light,
Nor certitude, nor peace, nor help for pain;
And we are here as on a darkling plain
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night.
This crushing statement of anxiety from Dover Beach is prefaced with seven critical words: " ... let us be true to one another." [1]
We have been true to one another and we have worked together to restore the conviction that, borrowing from William Faulkner, we will not merely endure, we will prevail [2].
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The transformation of the STS |
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TopIntroductionThe transformation of the...Innovation in clinical skillsQuality in health carePolitical engagementConclusion—our motivationReferences |
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What was our response in 1997 to the proposed 40% reduction in Medicare reimbursement? Did we whimper and whine and roll over? We did not! We voted a special assessment and raised 2.5 million dollars. We started a political action committee. We hired lobbyists. We hired a public relations firm. We developed key contacts in Congress. We formed alliances with neurosurgeons, orthopedic surgeons, cardiologists, ophthalmologists, and even dermatologists. We entered the political arena fighting for our patients and cut in half the proposed reduction and also delayed its implementation.
Our political mobilization has built up for the long haul. More than 150 of our members have been trained in health care economics and politics at The Thoracic Surgery Foundation for Research and Education (TSFRE) Harvard course. We were the only specialty asked to submit testimony to the Commission on Medicare Reform. Our members have successfully advanced a cardiac surgery demonstration project for the state of Virginia. Our Washington office, nearly nonexistent a decade ago, continues to steer us through hazardous waters. We navigate the storms of the professional liability crisis blowing over the feeding frenzy of personal injury sharks.
Outside of the political arena, we embraced the age of information technology, working with sister societies to create and "spin-off" The Cardiothoracic Surgery Network (CTSNet). CTSNet now represents forty cardiothoracic organizations worldwide as the global web portal for our specialty.
We found our database effort sputtering in the hands of our external manager. The database was rebuilt and taken "in-house" at a cost of over a million dollars. Now, with 545 current participants, it represents approximately 70% of U.S. adult cardiac surgery and is financially self-sustaining. It is expanding to congenital surgery and general thoracic surgery. Our database is used by states for quality monitoring, used by the Food & Drug Administration (FDA) for a contracted post-FDA approval study of transmyocardial laser revascularization, and used by industry as a platform for prospective clinical trials.
The database team then took the next step, using outcomes to promote best practices for the benefit of our patients. The database team won a federal grant to study the use of data management in improving processes in cardiac surgery. The STS is the only specialty society ever to receive such a grant and we have just been awarded a three-year renewal.
The STS determined its governance to be confining. New governance was created and STS management was moved from an association management company to a stand-alone management structure. Committees can now be created and dissolved overnight. We are just beginning to flex our organizational muscles.
As the STS has been transformed, it is working to help transform the specialty. Our annual meeting now has a major new technology component. Industry has been encouraged to bring new device training to our meetings. Practice management sessions, geriatric sessions, and a patient safety focus have been incorporated into our annual meeting.
As I end my term as your President, I am in awe of what you, my fellow Thoracic Surgeons, have created with your intellect and your energy. But this is just a good beginning. How do we move into the future with confidence? Let me discuss three areas in which moving forward is essential: innovation, quality in health care, and political engagement.
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Innovation in clinical skills |
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TopIntroductionThe transformation of the...Innovation in clinical skillsQuality in health carePolitical engagementConclusion—our motivationReferences |
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Innovative coronary bypass is here! Closed chest coronary bypass is estimated at 30,000 cases by 2008. No-clamp aortic proximal anastomoses should be part of your repertoire today. Off pump coronary bypass is 20% of coronary bypass today and is predicted to become 35% in five years [3].
Video-assisted thoracoscopic procedures are here today. Candidates sending data to the American Board of Thoracic Surgery submitted 1,915 thoracoscopic procedures in 1999 (9.7% of total general thoracic cases) and submitted twice that number (3,841 cases, 17.1%) in 2003. Lung volume reduction surgery was studied in the National Emphysema Treatment Trial (NETT) in 17 centers until 2002. In 2004 it is expected that 42 centers will be approved for NETT protocol lung volume reduction surgery.
Transmyocardial laser revascularization is here today with 5,000 cases in 2003 and more than 7,000 predicted for 2005 [3] (Fig 2). Heart failure therapy may be the biggest new part of our future. More than 500,000 patients in the United States are in congestive heart failure, with functional class III or IV symptoms and left ventricular systolic dysfunction. Operative therapy for atrial fibrillation is here today. There were 35,000 open-heart cases in 2003 that had preoperative atrial fibrillation. Less than 1 in 20 of these patients (less that 2,000 patients) had ablative therapy in 2003. A dramatic growth in surgical ablation is projected in the next two years (Fig 3) [3].
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Innovation brings with it a heavy responsibility. We must always remain patient-centered. We must evaluate and reevaluate new technology. We should always focus on new procedures that offer the most patient benefit. Beyond just responding to innovation, we must become the agents of innovation. We must develop new technology. The owners of new technology will be whomever does it best. If we are not the creators and the owners of innovation, then we will be the victims of innovation. If you do not participate in innovation, then you will be the victim of innovation.
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Quality in health care |
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TopIntroductionThe transformation of the...Innovation in clinical skillsQuality in health carePolitical engagementConclusion—our motivationReferences |
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I have exceeded the allowed number of times I may overrule guidelines.
"Hospital patient safety policy 1564 allows only four "overrules" per quarter in high-risk surgical patients. There is no limit on "overrules" for outpatients or medical service inpatients." Then the crusher: my provider certification is suspended! Now this is not a Federal Rule, it is a supplemental local hospital rule which my hospital committee instituted to show enthusiasm for the patient safety process. Fortunately there is always the HELP button!
An explanation of Suspension appears: I can provide care, but I will not be paid, and I have no insurance (Fig 4D). Great! Again, Options, but I have a bad feeling about where this parade is going.
AHa! I pick "Reinstatement!" (Fig 4E). After all, this is my First Suspension. Reinstatement will occur immediately after completion of RBUGD (that is, Remedial Basic Understanding of Guideline Doctrines). For my convenience, the three-session RBUGD class is offered monthly in the middle of the morning. I can sign up in March (of course, the February class is cancelled because of a Federal holiday).
My cries of anguish then resound through the operating room until the security officers carry me away. "Preposterous!" You say! I'm afraid not! Electronic Health Records, with guideline-directed control of medical care, are in the pipeline! You must believe this.
To help you believe, let me try to give you a ten-minute crash course on the patient safety initiative. Four years ago, we heard the thunder and lightning of the Institute of Medicine's report, To Err is Human: Building a Safer Health System [4]. "Patient Safety" is the thunderstorm, which has become, in 2004, the irresistible force in healthcare—first frightening, then cleansing, then nourishing growth.
We might ask about the Institute of Medicine the same question that Butch Cassidy asked the Sundance Kid. You remember, when they are on top of the hill looking down at the posse that they just could not lose and Butch says to Sundance: "Who ARE those guys?"
The Institute of Medicine was created by the National Academy of Science in its role as an adviser to the federal government on scientific and technological matters. And they seem to be as good and as relentless as Butch's posse.
Why are there tens of thousands of errors a day? Care processes are increasingly complex and a knowledge base is needed that is beyond the capacity of the human mind. I may know 90% of adult cardiac surgery, but I'm lucky if I know 5% of rheumatology.
To Err is Human estimated 44,000–98,000 deaths per year from medical errors of commission in inpatients [4]. Errors of omission may be more frequent than errors of commission. Studies have suggested that patients receive only 55% of care directed by current guidelines in acute care, in preventive care, and in the care of chronic conditions [5].
I fully endorse the response to the problem. The Institute of Medicine Report in 2001, "Crossing the Quality Chasm ..." called for change in the health care system to improve six national quality aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Patient-centeredness belongs right there in the middle. The report stressed the importance of robust application of information technology. And the report called for identification of priority areas for national action [6].
The 20 Priority Areas for National Action have been identified and six of the 20 are clearly our territory: #4 Cancer screening; #7 End of life with organ system failure—focus on CHF and COPD; #11 Ischemic heart disease; #14 Nosocomial infections; #18 Stroke; and #19 Tobacco dependence [5].
In response to the patient safety problem there has been a unified call for a National Health Information Infrastructure: "Urgent need for a 21st century health support system—a comprehensive knowledge-based system capable of providing information to all who need it to make sound decisions about health." There is a timeline stated in 2001 for the National Health Information Infrastructure, which calls for full implementation in Government and in the private sector by the 10th year [5].
In a focused response to the patient safety problem, Congress instructed the Agency for Healthcare Research and Quality (AHRQ) to establish a Center for Quality and Patient Safety. AHRQ then asked the Institute of Medicine to "produce a plan to facilitate the development of data standards" for patient safety information, to address the priority issues previously identified, and to identify the functionalities that computer-based clinical records should have to promote patient safety [5].
The Institute of Medicine has responded with its latest report, "Patient Safety: Achieving a New Standard for Care," released just two months ago in November of 2003. Quite honestly, it is full of invaluable directives for quality improvement. It requires a "Culture of Safety." A culture of safety is described as "... an integrated pattern of individual and organizational behavior, based upon shared beliefs and values, that continuously seeks to minimize patient harm which may result from the processes of care delivery." [5]
The latest report states that all health organizations should establish comprehensive patient safety systems that provide patient data and decision support tools. Patient safety data should be obtained as a by-product of care via an Electronic Health Record system. Care process failures should be identified and analyzed and this analysis should be used to create safer care systems [5].
The IOM November 2003 Report strongly supports the National Health Information Infrastructure stating that Federal authority and leadership should be used to develop data standards, which are then to be required for Medicare participation. In case you missed it, let me restate that last part: "to be required for Medicare participation" [5].
The report contends that Electronic Health Records are essential for patient safety improvement and should be sufficiently robust to support point-of-care safety checks, analysis of injuries, and near misses from acts of both commission and omission to the end that system improvement may occur. Point-of-care safety checks are important and they are coming [5].
The report urges that active research is needed to generate knowledge (eg, to identify high-risk patients or situations, to develop tools for automatic surveillance of the health care process to detect both adverse events and near misses, and to develop tools for on-line prevention of errors) [5]. Now this is beginning to sound like the scenario I presented earlier in this address.
Finally, the report states that a system should be developed for reporting near misses, adverse events, and errors of both commission and omission to the national patient safety database. Performance reports, whether for external accountability or for internal quality improvement, can be generated as a by-product of the Electronic Health Record system [5]. If you ever had any doubt that the electronic medical record was going to be used to evaluate your performance, you can kiss that doubt "good-bye." Performance reports are a logical and expected by-product of the system.
If you are not yet a believer that computer-based medical care for cardiothoracic surgery is in the pipeline, let me add one final national agency to your alphabet soup: the NQF, the National Quality Forum. The mission of the NQF is to develop consensus-based national standard for measurement and public reporting of healthcare performance data ... Is Cardiothoracic Surgery on the radar screen of the NQF? You bet we are!!! The National Quality Forum Website announced last summer: "NQF is pleased to announce initiation of a project, Standardizing Cardiac Surgery Measures. We are seeking nominations for Steering Committee members, which must be submitted no later than COB on Thursday, October 30, 2003..." [7]
In conclusion, quality in health care equals patient safety. This is not just my conclusion. It is the conclusion of the Institute of Medicine [5].
Health care processes, especially cardiac surgery, will be reengineered in the next decade as information technology is used to achieve dramatic quality improvement. Believe it—the change is well underway!
We have a window of opportunity! If we participate, if we seize the moment, we can make the system patient-centered. We can make this a computer-facilitated system rather than a computer-controlled system. We really can make huge progress in patient safety and quality.
This effort is national. The NQF steering committee on Cardiac Surgery Standards is chaired by one of our surgeons and includes two more.
Our Federal Grant is a patient safety grant from AHRQ. Your Society will be there!
But this effort is local as well. Every hospital, every office is to be required to have a local patient safety system.
Volunteer to help with patient safety in your hospital. Your patients' welfare can only be protected if you are at the table.
The Electronic Health Record can be our best friend and can do wonders for our patients or it can be our worst nightmare. By becoming involved now, nationally and locally, we can harness the energy of the patient safety thunderstorm for the benefit of our patients.
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Political engagement |
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TopIntroductionThe transformation of the...Innovation in clinical skillsQuality in health carePolitical engagementConclusion—our motivationReferences |
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Alas, the idealism that fired our early years simply could not withstand the incessant assault of human frailty. The instinct for personal gain, pride, envy, and elitism battered our fortress from the outside of medicine. But most regrettably, like the Great Wall of China, the walls of our fortress were never breached by external forces alone. These same elements of human frailty worked from within medicine and opened the gates of our fortress while we slept on our feather beds of self-congratulating idealism.
The fortress is breached and the walls are rabble. Society views organized medicine as groups of greedy, prideful elitists. What do we do? Do we abandon our idealism? Absolutely not! I did not get up this morning to whimper the day away and fade into the sunset. Neither did you!
We do two things. First and most importantly we reaffirm our idealism with every patient we touch. By recognizing and respecting the divine spark in every soul whose pain we treat, we rekindle the spark that lights our own lives.
Second, we do what we thought what we would never do. We do what the rest of society does. We embrace politics! Politics is not an abomination. Indeed politics may be the resurrection of our idealism. Politics, you see, is the reconciliation of the ideal with reality. It is the reconciliation of what should be with what is. We must be there when society defines what should be in health care. The electronic medical record problem I described earlier suggests what can happen if we fail to represent the interests of our patients.
The STS is engaged, speaking for our patients on the national level in a joint effort with the American Association for Thoracic Surgery. Our Washington initiative has been effective. Depicted in Figure 5 is Medicare reimbursement for three-vessel coronary bypass since 1997. The yellow line is the planned reimbursement. The upper is the actual reimbursement as we have successfully moderated the proposed cuts. In 2004 we actually gained a 4.5% increase as The Centers for Medicare and Medicaid Services (CMS) finally accepted data from an STS survey on practice expense. We began our active political engagement in 1997 with a $1000 per member assessment that raised 2.6 million dollars. Our cumulative expenditure over these seven years has been 5 million dollars from the assessment and STS dues, plus $800,000 in voluntary contributions from our Political Action Committee (PAC) and $400,000 from the AATS. In that seven years, the difference between proposed Medicare reimbursement and actual reimbursement has been 1.36 billion dollars. (Fig 6) This has been a 219:1 return on our investment, just from Medicare payments alone, not even counting other fees indexed to Medicare.
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Speaking of whether we are doing enough, it is essential to take two minutes to consider our Political Action Committee. These voluntary personal contributions can be used differently from Society funds. PAC donations allow the arguments that we make for our patients to be heard by legislators and by their aides. It's not my favorite part of the political system, but it is a part of the system. We must support our PAC. Thoracic Surgeons are on the low end of PAC contributions, compared with other groups like the trial lawyers and other medical specialists.
We have crisis in the PAC. We have given $125,000 in this election cycle and most of that has been spent in professional liability battles last year. Only $16,500 is left. What should you give? With regard to the PAC there are three categories of givers. There are freeloaders who give next to nothing and somehow seem to be the people who complain the loudest. There are sustainers who give at least $1 for every major case they do. There are engaged surgeons who give $1000 or more per election cycle. These leaders are needed to carry the freeloaders.
I want to plant a POP-UP notice in your brain. Whenever you are about to vent about reimbursement or liability costs, I want that window to pop up in your mind. I want you to hear me say: "Before you complain, have you done the small part we asked you to do, have you given at least $1 per case to the PAC?" Don't be a freeloader. From the words in Dover Beach "... let us be true to one another." That is the only way we can defeat the "ignorant armies clashing by night."
Let me finish with a comment about what we must do on the local level. In the hot days of August of 2002, John Puskas and I decided to host a fundraiser from physicians for a political candidate. Now this candidate was a long shot. He was given a snowball's chance in South Georgia of winning.
To help recruit physician support, we asked his office to gather together his previous policy statements and to frame a letter stating concisely his support for stopping the decline in physician Medicare reimbursement and supporting meaningful federal tort reform. We included that letter in more than 300 invitations. We made multiple phone calls. Finally, we had a successful fundraiser in John Puskas' home on September 14, 2002 for Saxby Chambliss with five cardiac surgeons, ten other physicians, three patients, and a contribution from the STS PAC. On that same weekend, the opponent, Senator Max Cleland, was in Florida at the national meeting of the American Trial Lawyers Association. To our surprise and everyone else's, Saxby Chambliss was elected, giving us an ally and shifting the balance of power in the U.S. Senate.
This is another election year. Our Washington efforts are useful, but nothing is more important than getting people elected who agree with us on issues relating to our ability to serve our patients. And the best time to discuss those issues is during the election. This is how our democracy is supposed to work.
We ask for your ideas, your intellect, and your energy in helping your Society proactively move ahead. But beyond that I challenge you to make a personal commitment to progress. I challenge you to do the following three things: (1) Learn at least one new operation this year; (2) Choose a local patient safety project in your hospital and lead it this year; (3) Don't be a freeloader. Give $1 per case to the PAC and host or at least attend a fundraiser for a candidate this year.
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Conclusion—our motivation |
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TopIntroductionThe transformation of the...Innovation in clinical skillsQuality in health carePolitical engagementConclusion—our motivationReferences |
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Years ago I used to write. Usually late at night. Usually focused on the college student's search for meaning, for purpose. Usually struggling with the reconciliation of idealism with reality. I still have a small package of those writings. One of those, written at the time of the death of Martin Luther King, Jr, poses an unfinished task:
Must I grow up?
How it hurts to see the world as it is
For years I've known
That men are less than they should be
Now I fear I only begin
To see how much
Is there not one honest human
Who dares to face
All of the truth?
I cannot, I will not
Accept this state
I throw the gauntlet out,
Hopeless as the joust may be!
Rather I would face all the rest at once
Than this one I must first subdue
But I know there's no one else,
I must begin with me
Thirty-five years later, I'm still working on me. Like you, the path I chose was very focused. We worked. We studied. We worked. By day and by night. Week after week. Month after month. College contemporaries of ours became millionaire businessmen, engineers, and lawyers. Was it worth it? Am I better off than Joe Johnson with his lodge in Vail and his compound in the Caymans?
DARN RIGHT I AM! You see, I called 21 ICU an hour ago and Mr Malone has an index of 3.5 and moves all four to command. Mr Malone, you see, was just in Atlanta on business from Charlotte. Then his chest hurt and he couldn't breathe. He hit the emergency room cold and sweating after 24 hours. His left ventricular end-diastolic pressure (LVEDP) was 38 and his ejection fraction (EF) was 20. His baggy heart was cursed with diabetic strings for vessels. Worst of all was the pain, over and over, the pain. V-fib after induction. No blood pressure except from compression until the internal paddles kissed his departing soul. Eight of us, a team working together almost wordlessly, held Mr Malone's heart in our hands yesterday. Today his index is 3.5 and all four move to command.
Do we share this, you and I? Do you feel the intensity that I feel with every operation? It is the Grand Joust in the Tournament, and each time the opponent, the one I must subdue, is myself. I must defeat my self-doubt with preparation. I must battle my ignorance with knowledge gleaned from others. I must overcome inattention to detail with focus and commitment. I must fight the unexpected with tenacity. I must overcome progressive limitations of physical skill with experience. I must subdue my pride with the understanding that the squire and the armorer and the horse are often more critical than I. Mostly I win. Sometimes I'm knocked on my rear end! But every time there is the rush, the feeling of a unique and personal contribution to the interdependency of human souls. Yes, we share Mr Malone, you and I.
We are fortunate, you and I. We are fortunate to taste this aphrodisiac almost daily. But the Operating Room is a treacherous mistress. The operation is a great and singular event, but it is a problem, this intoxicating total immersion into responsibility for another's life. Tasks of daily living and daily work seem less vital, almost trivial sometimes by comparison. Importantly, the activities that we must undertake to preserve the environment in which we work, to preserve the opportunity to help our patients, present very delayed gratification compared with Mr Malone.
Surgery is threatened today. We must reinvent ourselves not only to adapt to changing technology, but also to be the initiators of progressive change. We must work together to defeat the forces that would reduce us to operating room technicians. We must become the champions of quality and value in medicine. We must be tenacious advocates of patient education and empowerment.
There are mountains to move. I believe that great mountains are moved by great faith. But mountains are moved stone by stone and the faith that moves mountains is the faith that you will carry your stone and I will carry mine. And we carry these stones, not for you, not for me, but for Mr Malone.
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References |
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TopIntroductionThe transformation of the...Innovation in clinical skillsQuality in health carePolitical engagementConclusion—our motivationReferences |
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- = actual Medicare fee by year; -
- = proposed annual Medicare fees, under HCFA 1997 PE Proposal Work RVU's prior to 2002 revisions, and by year conversion factors (2003–2005 without Congressional corrections). (PE = practice expense; RVU's = relative value units.)