The Imperative for Change
2011; Elsevier BV; Volume: 91; Issue: 6 Linguagem: Inglês
10.1016/j.athoracsur.2011.03.072
ISSN1552-6259
Autores ResumoIt is both an honor and a privilege to be able to address you as the President of the Southern Thoracic Surgical Association [STSA]. Many gifted surgeons have preceded me in this role. I am sure that when you remember the long line of superlative physicians who have served in this capacity, you will all be struck by the same thought: “What in hell is Keith doing up there and what was that nominating committee smoking?” Regardless, I now have the privilege of addressing you, my friends and colleagues in the STSA. In order to learn how to comport myself during my presidency, I sought out Mike Mack for advice and he uttered but a single word: “Gravitas.” I wasn't absolutely certain what that meant. I thought I remembered from medical school that it was some form of intestinal gas but Mike corrected me and said that Gravitas is a quality or substance or depth of personality and that I could learn from his example, that he possessed Gravitas. So I looked back over the multiple photos of Mike during our last few meetings and found images of him riding a plaster horse, modeling a ridiculous looking Stetson hat, and dozing at the microphone when moderating a paper session. I must now surmise that Gravitas means one is capable of making an ass of oneself in public and so, Michael, thanks for convincing me I have what it takes to do this job. Rich Prager has already given you a mini travelogue on how I came to hold this position, in this place, and at this time. Like everyone else who has stood here, I realize that anything that I have accomplished has as much to do with the efforts of others as it is to any of my own personal work and some thanks are in order. When I finished my first year of medical school I decided to spend the summer in the cardiac physiology lab run by this man, Bob Replogle, who was then Chief of Cardiac Surgery at the University of Chicago (Fig 1). As any of you who know Bob are aware, he has a somewhat rough exterior, which is really just camouflage for a man of warmth, endless humor, and insight…..plus a penchant for profanity that would make a sailor blush. The morning that I first met him the first sentence out of his mouth was both so funny and so profane that I thought he had to be a truck driver or a drill instructor. The lab staff assured me that, no, he is actually a surgeon and I can remember thinking to myself. “Damn, I think I may be able to fit in here.” At the University of Chicago, I also walked in the shadow of these three gentlemen, who I think of as the Holy Trinity of esophageal surgery (Fig 2). This picture shows David Skinner looking in over the case being performed by Tom DeMeester who is being assisted by Sir Ronald Belsey. Although I have no inkling of who the patient actually was, the odds are that the poor man could not swallow worth a lick prior to his surgical repair. It was through the influence of these three gifted surgeons that I became drawn to the practice of thoracic surgery. They were the stars, the studs, the cool guys; and my goal was then and is now to become a master surgeon like those three. It continues to be a work in progress. I stayed at Chicago for both general surgery and my cardiothoracic residency. During that time, I wasn't the only one to fall under the spell of David Skinner and company. My co-residents included Alex Little, Mark Ferguson, Carlos Pellegrini, George Wernly, Jim Levett, Nasser Altorki, Walter Scott, and Darryl Weiman, all of whom continue in academic thoracic surgery to this day and all of whom remain close friends. I consider myself very lucky to have been in the right place at the right time and with the right people. When I finished in 1985 I landed my first and, in fact, my only job at Saint Louis University where I was hired by someone most of you know, George Kaiser. The other cardiothoracic faculty at the time I joined the department included Vallee Willman, Rick Barner, Glenn Pennington, Art Baue, and Larry McBride. These gentlemen provided me the inspiration, guidance, and support which fostered both my clinical and my academic growth and for that I will be eternally grateful. Three of these gentlemen, George Kaiser, Rick Barner, and Glenn Pennington, have served as the Southern Thoracic Surgical Association President, as has my current senior partner, Dr Bill Sasser. I am honored to be the fifth member of the Saint Louis University faculty to serve as STSA president. I am also indebted to my current colleagues at Saint Louis University who include Bill Sasser, Rick Barner, Andy Fiore, Robbie Johnson, and Emily Farkas. They are the reason for the continuing success of our division and their efforts allow me to have the time to serve both the STSA and the Society of Thoracic Surgeons. I must also thank our administrative staff, especially my administrative assistant Laura Bianchi. Our relationship is characterized by the age-old axiom–would you rather talk to the man in charge or the woman who knows what's going on? We have worked together for nearly 23 years and I could not have achieved a fraction of what I accomplished without her efforts. After all, someone in the office had to be organized, thoughtful, and mature, and that sure as hell does not describe me. Laura is here today with her daughter and I'd like to publicly thank her for her patience, devotion and effort. Finally, my family is here with me today. I am of course, deeply indebted to my parents for their love and support. Unfortunately my mother passed away two years ago and I am very sorry you all did not get a chance to meet her; you would have loved her. She was a woman of intelligence, grace, and charm, and would have fit in well here at the Southern. But my father, 86 years young, is here with us today. He actually insisted on coming to find out what kind of misguided organization could possibly have elected his idiot son into office. I am also supremely grateful to my wife of 32 years, Rosanne, who, in addition to her full time job as Professor of Medicine at Washington University, has raised our four children almost single handedly while I was gallivanting around the hospital or to meetings such as these. My four kids are here and having them together in one place is a tremendous but infrequent joy for Rosanne and me. The eldest Kate is a Stanford grad who is now a financial analyst, Ted is a third-year University of Missouri law student, Matt is in his fourth year of a combined MD-MBA program at Harvard, and Molly is a second-year medical student at the University of Chicago, the alma mater for both Rosanne and myself. My message to my children is a simple one. “I am extremely proud of the people you have become; thank you all for the joy you have provided to both your mother and myself over the years. . . . . . and . . . . . . oh . . . . . . yeah . . . . don't do drugs!” This talk is a privilege to present but has also proved to be a burden of sorts over the last year. I use the word burden because I believe the presidential address is a love-hate experience for most every society president. On the one hand, one can't help feeling honored. You are anointed and awarded the privilege of the presidential address. On the other, there is significant pressure to deliver a lecture that will both inform and energize one's colleagues on a topic pertinent to the specialty. And like every other president, my greatest fear is a wave of boredom and mass somnolence replete with snores, grunts, and unseemly drooling. To prevent just such an event, I sought out advice regarding an appropriate topic from past presidents. I first called Bob Sade, our resident saint and the do-gooder of the STSA. As you might expect, Bob suggested an address dealing with a philosophical topic and when I pressed further he suggested it would be best to address a fundamental ethical dilemma or some profound danger facing our association. I asked which danger he was referring to he and he said that my election to this office was about as profound a danger as the STSA has ever faced. There was also some unsolicited advice. Ranny Chitwood actually called me to offer his thoughts on topic selection. You all know Ranny, he's the common man of Southern thoracic surgery, the kind of down to earth guy who has hankerin' for guns, girls, and grits. He's so Southern he actually changed his academic title at East Carolina to the NASCAR Professor of Surgery. Well, he called and was talking in that thick Southern country boy drawl and I think he was proposing a topic for my address. I'm pretty certain I could make out the words “cousin” and “tater” but I am really not fluent in Bubbaspeak so I really didn't get the gist of what he was saying. So I just thanked him and wished him and his “houndog” Blue a good day. My final call went to my long time friend Carolyn Reed or Queen Carolyn as she is known to her close friends. Carolyn and I have been friends for 25 years and she has been one of the most prominent women in our specialty. I asked her what my topic should be and she suggested that I play to my strengths. I waited for her to enumerate them but after 15 seconds of dead silence, I suggested to her that perhaps I could speak to the importance of the women's movement in cardiothoracic surgery. She told me that if I tried that, it would make a mockery of the efforts of people like Elizabeth Blackwell, Gloria Steinem, and Susan B Anthony. When I asked “Who the heck are those chicks?” the connection suddenly went dead. In truth, I did speak with many people about this talk and there was one common theme to the advice from all of them. To a person, they advised that my address deal with an issue or issues about which I feel passionate. I thought about that and realized there are a myriad of issues affecting thoracic surgery which incite within me real emotion. Take, for example, the 80-hour work week. I do recognize that this limitation of resident hours has been beneficial to the personal lives of residents and that's all well and good. But frankly, although it's politically incorrect to say it, I believe the work-hour limitation is tragically misguided. It was instigated by a media mogul who insisted resident fatigue was responsible for the tragic death of his daughter. The concept that resident fatigue resulted in harm to patients was “sexy” enough to be picked up and trumpeted by the press, sensationalized in congressional hearings, and ostensibly corroborated by a series of articles out of Boston which I believe to be highly sophisticated junk science. The ACGME [Accreditation Council for Graduate Medical Education] swallowed these arguments whole, bowed to the pressure and mandated the limits we have today. This was all done with absolutely zero credible evidence that the prolonged work hours endangered patients. Zero. In the six years since the limit was instituted, there is little or no data documenting improved patient safety. In fact, there is data to suggest that patient safety has actually been compromised due to faulty communication during handoffs. And, in addition, I and a great many educators believe that resident education has suffered significantly. Passionate? Yeah . . . . . .please don't get me started. Another sore spot is the electronic health record, or EHR. This has been instituted at our hospitals and admittedly there are some bright spots with electronic records, specifically the availability of imaging studies and simultaneous access to charts by multiple individuals. But there is a huge cost, both financially and professionally. The fiscal costs include acquisition of hardware, software, appropriate personnel, and maintenance costs. Although it's affordable for large institutions, it's hard to swallow for most small to medium size practices. From the professional standpoint it has been universally noted that there is decreased clinical productivity when instituting these systems. With virtually all of these programs, physicians are forced to do clerical work previously undertaken by nurses and secretaries. Interoperability also remains a significant problem, meaning that the EHR in my office won't necessarily communicate with the EHR in my hospital or my referring physicians' office. In fact, it appears this whole IT transformation is being instituted on little more than faith alone. Other than CPOE, or Computerized Physician Order Entry, there is minimal data demonstrating that any computerized system improves patient safety and virtually no data demonstrating any cost savings except in large multispecialty clinics. Frankly speaking, the push for EHR comes not from practicing docs but rather from the media, industry, and government bureaucracy. Yeah, I'm passionate about this issue too. I realized there are many such issues that anger and puzzle not only me, but most of my colleagues in thoracic surgery. These included the Medicare SGR [Sustainable Growth Rate], the cardiothoracic applicant shortage, the imposition of the six maintenance of certification competencies, HIPAA [Health Insurance Portability and Accountability Act] rules, and any number of items in the recently passed health care reform bill. The common theme for all these issues is change being forced upon us from outside our profession. Thus I decided to direct my address to the topic of change and how we as thoracic surgeons should deal with it now and in the future. I first realized that CT [cardiothoracic] surgeons can have trouble accommodating to change about 15 years ago when my boss George Kaiser walked up to me one evening while I was standing at the shredding machine destroying some old patient files. He hurried up to the machine with some documents in his hand and said “Thank God you're here! This new technology makes it so hard to keep up. I really need help using this machine. Can you help me feed these in correctly? ” He handed me the documents and just as I fed them into the shredder he turned to me, put his arm around my shoulder, and said “Thanks again Keith, you're a lifesaver. I only need a couple copies.” Every human being tends to become set in his or her ways and thus change is an uncomfortable, if not fear-provoking, process for virtually all of us. However, it's important both for us personally and for our specialty that, with regard to change, we see both sides of the coin. We must recognize that it is inevitable but should also realize it's potentially invaluable. In fact, change is integral and necessary for the survival of our specialty. But we cardiothoracic surgeons may not handle the ongoing changes as well many other specialties. When you think about it, that's really not a huge surprise. Let's face it, thoracic surgeons historically have not been recognized as flexible individuals, sensitive to the subtle shifts of their surroundings, and who welcome the idea of fundamental change . . . . . . unless it's their idea. Just ask any one of our spouses. According to Betsy Urschel it takes a major tectonic shift in the Earth's crust to get Hal off his rear end to change anything around the house. You have to ask yourself why that would be and the answer is simple. Think back to your own career selection and, perhaps more importantly, to those who guided and enabled your selection of cardiothoracic surgery as a career. What character traits do you think that the chairmen in thoracic surgery selected for 30, 20, or even 10 years ago? Certainly intelligence was a factor; we were all intelligent, but so were the folks who went into Internal Medicine. I would suggest to you that we were not chosen primarily for sensitivity, flexibility, or our willingness to compromise. We were selected for reliability, stamina, and the emotional toughness to follow orders and see a task through to completion. Most of us were not chosen because we had a gift for independent thought or an ability to innovate. On the contrary, we were chosen at least in part for our ability to follow orders. I doubt there was ever a single Duke trainee who said “Gee Dr Sabiston, I know what you told me to do but I did something different because my way was better!” Well, it's possible there were one or two trainees who said that…but I can guarantee you none of them finished the program. Now I'm not trying to impugn Dr Sabiston or Duke University. It was the same at Mass General, Hopkins, Michigan, Mayo, and even the University of Chicago where I trained. Let's face it, deviating from the prescribed path was not a good career move in any cardiothoracic program. As residents, we were not allowed to change anything. How often did we hear “my way or the highway”? Most of us came to accept the way in which we trained as the gold standard and have tried to perpetuate that same system for our own trainees. We are now under external pressure to change that system and, frankly, we don't like it. We want what we want, when we want it, and the way we want it. There is, after all, more than a kernel of truth in the version of the old lightbulb joke which asks how many thoracic surgeons it takes to change a light bulb? The answer? Just one . . . . . .he puts the bulb in the socket and the world revolves around him. But it is not that we absolutely refuse to change. Although we as individuals tend to resist change in the short run, our specialty has evolved continuously in the clinical arena and in fact that is the only reason our specialty has survived over the past hundred years. The whole history of cardiothoracic surgery is one of slow and constant change with a capital C (Table 1). Thoracic surgery was being actively performed over a century ago, and at that time tuberculosis was known in the vernacular of the day as consumption. Consumption was initially treated by intrathoracic lysis of adhesions or thoracoplasty to collapse the lung. Eventually treatment evolved to include resection of diseased lobes and segments. But once effective anti-tuberculous medication became available in the 1950s, a large fraction of the thoracic surgeon's business disappeared into TB sanatoria. But simultaneously our practices were changing as well. While one source of patients gradually vanished, another appeared after Evarts Graham attacked and conquered the second C in our evolution, cancer of the lung. In 1933 Evarts Graham performed a successful pneumonectomy for cancer opening up a whole area of practice for chest surgeons.Table 1Change With a Capital “C”Consumption - pneumolysis, thoracoplasty, resectionCancer - pneumonectomy, lobectomy, segmentectomyCongenital heart - PDA, shunts, complex cardiac repairsCardiac valvotomy - closed, open, repair/replacementCoronary bypass - off pump, on pump, off pump, on pumpCardiac arrhythmia -WPW, vent. tachycardia, atrial fibCongestive failure - heart Tx, VADs, vent. remodelingCOPD - lung Tx, LVR, giant bullectomyCOPD = chronic obstructive pulmonary disease; LVR = lung volume reduction; PDA = patent ductus arteriosus ; Tx = transplant ; VAD = ventricular assist device; vent. = ventricular; WPW = Wolff- Parkinson-White. Open table in a new tab COPD = chronic obstructive pulmonary disease; LVR = lung volume reduction; PDA = patent ductus arteriosus ; Tx = transplant ; VAD = ventricular assist device; vent. = ventricular; WPW = Wolff- Parkinson-White. The next C in our evolution represents congenital heart disease, first successfully treated by Dr Robert Gross, who performed a PDA [patent ductus arteriosus] ligation in 1938. The Blalock-Taussig and Potts shunts would follow within the decade and thus congenital heart surgery was off to the races. Cardiac valvotomy was next and was first successfully performed by Horace Smithey in 1948. This represented the inception of modern day valvular surgery. Coronary bypass was next, accomplished by Geotz, Kolesov, and Favoloro independently all in 1960s. Cardiac arrhythmia surgery was initiated in 1968 with successful division of an accessory AV [atrioventricular] bundle for Wolff-Parkinson-White and, since that time, ablation procedures for ventricular tachycardias and atrial fibrillation have been developed. Congestive heart failure was surgically addressed, first by transplantation and more recently with VADs [ventricular assist devices] and ventricular remodeling procedures. COPD [chronic obstructive pulmonary disease] has been tackled surgically using lung transplantation and lung volume reduction. Within the past 20 years, the changes have been fast and furious and they have served to further demonstrate that CT surgeons can innovate and do indeed evolve, at least in the clinical arena. And for us to survive as a specialty, such innovation will have to continue. This is because many of our surgical procedures gradually become obsolete as advances in technology allow for the noninvasive management of diseases which previously required our intervention. The first example of such change in our history was the discovery of streptomycin and the other antibiotics used to successfully treat tuberculosis. When the value of medical therapy was recognized it effectively supplanted surgical resection for the treatment of TB. Frankly, this should be the natural order of things as it allows for less morbid and invasive disease management. In the near future, many of our current bread and butter procedures may also decline due to nonsurgical therapeutic advances, whether it be stereotactic radiosurgery for lung cancer, umbrellas or coils for congenital defects, transcatheter valve implantation, stents for coronary disease, or catheter ablation of arrhythmias. Our specialty must continue to evolve and explore new frontiers if it is to survive, and so far we have been successful. But the keys to our successful change, the primary factors that make us willing to change, are two in number. First is the existence of definitive evidence, hard data which supports the proposed change. We are by nature a relatively conservative and skeptical specialty, but once definitive evidence is provided documenting prolonged survival or improved function, we can change with the best of them. The second and perhaps more important factor is that of autonomy; that is to say that we are more willing to change when the decision for change is ours and not one foisted upon us by outside agents. We want to control the decision process. As all our spouses know, there is no bigger control freak than a cardiothoracic surgeon. For most of the 20th century CT surgeons were at the top of the pile and in charge of every facet of their own practices. But now we have entered the 21st century and suddenly external forces are increasingly being exerted on us, pressuring us to make changes in all aspects of professional lives. These are not just pressures for clinical change; as we've seen, we can handle that ourselves. These are changes outside our comfort zone, in the fiscal, social, political, and education arenas. However, unlike the clinical realm where science and hard data abound, there is a dearth of evidence documenting value for these nonclinical changes. Such changes appear to be pushed ahead not by evidence but by whim, prejudice, media frenzy, public opinion, or regulatory fiat. This combination of a dearth of supportive evidence and our loss of autonomy lead us to resist such changes. There are many examples. I've mentioned the 80-hour work week and electronic health records. In addition there's. Physician Quality Reporting Initiative or PQRI, specialty specific quality guidelines which mandate specific processes of care. But they don't measure real clinical outcomes and there's no evidence they are improving patient care to date. Another mandate from outside. Six competencies of Maintenance of Competency (MOC). The American Board of Medical Specialties (ABMS) attempted to answer the challenge from Institute of Medicine (IOM) to objectively and quantitatively measure the clinical competence of the practitioner. Critics complain of the expense and paper work with little of obvious value to show for it. This process is certainly not optional and has been mandated from without. The Medical Home, the latest concept to revamp Medicare payments. An appealing idea but there is no data . . . .zip, zero, zilch, rien, nada…no hard evidence that these changes will either lower expenditures or improve outcomes; in the published pilot projects, costs have been demonstrated to actually increase without meaningful clinical improvement. This is an appealing idea to government, fueled by media hype as well as a burning sense of frustration on the part of primary care physicians. In general, these types of changes have not been warmly embraced by cardiothoracic surgeons, and from the tenor of my remarks you might naturally think that I am against these changes, that I would want to fight them tooth and nail and urge you to do the same. And . . . . . . . . . . . .you. . . . . . . . . .would. . . . . . . . .be. . . . . . . . .wrong! It's obvious that I do not really like the changes any more than you do but actively fighting them makes no sense. It's a little like arguing with your spouse. . . . .even if you win the argument, you end up losing. Our goal should not be to stop or reverse the changes; that's like trying to beat back the tide. Instead we need to respond constructively and try now and in the future to guide such changes for the betterment of our patients. Learning to manage such change both personally and professionally would be one of the most constructive educational endeavors our specialty could undertake. One of the first things we have to do is quash the notion that any of us can just hold onto the status quo and ride out the rest of our careers in blissful ignorance. Change is going to continue whether you want to participate or not. If your practice or your division or your department is not changing so much you can hardly stand it, then it is not likely to be around five years from now. If you choose not to participate, you will be left in the dust. My job, your job, our job is to deal with that change as effectively as possible both for our own benefit and for that of our patients. Change is truly hard for all human beings and experts suggest they are four basic responses evoked in those confronted with change. Some will be dismayed and react by whining. These “whiners” will take little or no action but will grumble continuously. The second group is known as the “bystanders,” those who stand apart, neither supporting nor opposing the change. These folks just want to stay under the radar and maintain the status quo. A third group is comprised of the “critics,” those angry and vocal people who complain loudly about the injustice and actively oppose any sort of change. Finally, there are the “navigators.” These tend to be the early adopters who recognize that some form of change is inevitable and actively participate in the process with hopes of guiding the change in directions that prove to be constructive. We as cardiothoracic surgeons need to take a hard look at ourselves, recognize in which of these groups we currently reside, and decide how we plan to cope with the future. While whining may be somewhat emotionally rewarding, it obviously does nothing to address any problem. Taking the role of a bystander on the sidelines may avoid stress in the short run, but there will come a time to pay the piper. Getting angry and becoming a vociferous critic? Although it may be cathartic, anger is rarely constructive and tends to impede progress. The best response we can have is also the hardest to carry out; that is to actively engage ourselves in the process of constructive change, navigating towards the best possible result. This requires intelligence and perspicacity, two attributes CT surgeons possess in spades. But it's also advantageous to demonstrate flexibility and the capacity to compromise. And for most of us, that frankly is not our strong suit. Our specialty is populated by some of the most intelligent, energetic, and capable beings on the planet. Now we just need to make a conscious effort not to whine, not to sit on the sidelines, not to complain angrily about what's not fair. Our goal must be to navigate the change ahead of us and for that we have some great role models right here among us at the Southern Thoracic Surgical Association (Table 2). Just a few years ago the specter of catheterization-based valve replacement loomed large on the horizon and some in our profession predicted that percutaneous valve placement would effectively supplant open repair or replacement, thus rendering the surgeon unnecessary. Some of us just moped or whined, some just stuck our heads in the sand, and many got angry, but not Mike Mack. In conjunction with Fred Mohr, Craig Smith, Joe Bavaria, and others, he acquired the technical skills to participate in minimally invasive procedures. These investigators fostered cooperation between surgeons and cardiologists and in doing so helped institute the Partner Trial. Perhaps more importantly, Mike and the others are holding training symposia to pass on these skills to their other surgeons so that we might all better prepare for the onrushing future. Because of Mike Mack and other surgeons like him, CT surgeons will now have a solid foothold in the arena of minimally invasive valve replacement.Table 2Society of Thoracic Surgeons Supplement Members Who Have Navigated ChangeMichael MackPercutaneous valvesPARTNER TrialRichard FeinsPaucity of applicantsSix Year Integrated CT Surgery ProgramCarolyn ReedDearth of female applicantsWomen in Thoracic SurgeryJohn CalhoonLack of entry level skill/knowledgeTSDA Cardiothoracic Surgery Boot CampWalter MerrillLack of entry level skill/knowledgeTSDA Cardiothoracic Surgery Boot CampPeter SmithDeclining reimbursementAMA Relative Value Update CommitteeJohn MayerLack of political influenceBridge b
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