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Rewards, risks, and responsibilities of globalization for the cardiothoracic surgeon

2007; Elsevier BV; Volume: 134; Issue: 1 Linguagem: Inglês

10.1016/j.jtcvs.2006.09.067

1097-685X

Richard A. Jonas,

History of Medical Practice

It is a tremendous honor for me to be standing before you today as the 87th president of this august and proud academic organization. I am truly humbled to be here standing on the shoulders of giants, individuals of vision and energy who have shaped this Association to be what it is today. This Association is a brilliant public symbol of the importance of the academic mission for the present and future of cardiothoracic surgery. By awarding membership, the Association pays tribute through peer recognition to those who make significant contributions to teaching, research, and clinical surgery. When I became a member of the Association, I considered it one of the greatest honors of my professional career. As a foreign medical graduate from Adelaide, South Australia, to be president of this Association feels like the ultimate realization of the American dream, proof that all doors are open in this great land of opportunity. I am not alone on this podium this morning. There are many wonderful people who share this honor with me today: first and foremost, my immediate family, my three children, Andrew, Michael, and Nicole Sofia, of whom I am tremendously proud, and my beautiful, loving wife, Katherine, who has counseled and supported me through the challenges and complexities of life, as well as my extended family, all of whom live in Australia. My assistant for 23 years, Laura Young, has quietly and calmly managed my increasingly complicated life with the most remarkable efficiency and organization. Laura's vast memory not only includes details of grant deadlines and council meetings but also extends to remembering touching personal details of patients and their families from decades ago. Surely one of the great joys of being a congenital heart surgeon is that most of our patients lead long and productive lives, so that over time we accumulate a vast extended family. The holidays are a wonderful time when cards arrive from around the country and around the world. The support and encouragement of so many of these families is also with me this morning. I mentioned this morning in my introduction my gratitude for the managerial efficiency of our management organization, the Professional Relations and Research Institute of Boston. I am also indebted to the council members and officers of the The American Association for Thoracic Surgery (AATS) (Figure 1). I would also like to thank Dr Andrew Wechsler, the Editor of the Journal of Thoracic and Cardiovascular Surgery, who will be stepping down at the end of next year. Under his direction the Journal has been nurtured through a tremendously demanding time of transition from paper to electronics. Not only has this been accomplished with efficiency and intelligence but, in addition, the academic rigor, innovation, and readability of the Journal have never been better. At the Children's National Medical Center in Washington, DC, which has been my home now for nearly 2 years, it has been a pleasure to work with an outstanding group of individuals. I am particularly fortunate to be working with Dr Gerard Martin, who is co-director of the Heart Institute and chief of cardiology (Figure 2). The relationship between cardiology and cardiac surgery can be a fragile one, particularly in an area of shifting finances and power within the hospital structure. Today we are collectively successful in shepherding children with congenital heart disease through even very complex reconstructions with an overall success rate approaching 98% to 99%. However, this results in a cumulative pool of patients needing life-long follow-up with cardiology but, ideally, rarely if ever with cardiac surgery. Within my professional lifetime, congenital cardiology departments have grown from being equal partners to being up to 10 times as large as surgical departments in terms of numbers of physicians and with increasing financial disparity. This is leading to stresses within congenital cardiac programs. But such stresses can be minimized by an administrative structure such as exists at Children's National Medical Center, where all decisions as well as hospital and professional revenues are managed collectively by the physician and administrative staffs. My journey to this podium has been a long one, but it has also been enormously satisfying and rewarding. As surgeons we are blessed to have families place in our hands the responsibility of caring for their loved ones. We have an opportunity to practice both an art and a science, to enjoy the consummate satisfaction of applying practiced physical skills and the fundamentally humane activity of supporting and encouraging and sometimes grieving with families who are passing through an incredible period of stress in their lives. My journey to this podium would not have been possible without the support of my surgical mentors, to whom I would now like to pay tribute and give thanks by briefly tracing my educational progress halfway around the world. My mentors worked within quite different health care delivery systems. My direct experience with these different systems has no doubt shaped my views of the global challenges and opportunities facing cardiothoracic surgeons that I will share with you this morning. My journey began in Adelaide, South Australia, best known as the home of the Australian wine industry (Figure 3). As a medical student at the University of Adelaide, I worked within a health care system that in those years was a reasonably successful balance of private and public funding. However, in the tradition of the British model, private and public patients were segregated into private versus government hospitals. One clear lesson that I took away from that experience was that if ever I was to be undertaking complex surgery in patients who would require intensive care management postoperatively, I would confine my practice to one hospital. This principle was reinforced by my mentor and good friend, Dr D'Arcy Sutherland, who established open heart surgery in Adelaide and who set me on the road to this podium (Figure 4). D'Arcy was a master surgeon, a tremendously successful administrator, and one of the first in the world to recognize the importance of the careful collection of risk-adjusted registry data. At the very first AATS meeting that I attended in San Francisco in 1980, D'Arcy was the honored guest speaker. D'Arcy is alive and well in Adelaide and sends his best wishes to his many friends in the AATS (Figure 5).Figure 4H. D'Arcy Sutherland, a pioneer of heart surgery in Australia and past president of the Australian College of Surgeons.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5The author (right) with Dr D'Arcy Sutherland in Adelaide, South Australia, 2004.View Large Image Figure ViewerDownload Hi-res image Download (PPT) During my medical student years I had the opportunity to work for 3 months in the National Health Service in the United Kingdom. I was surely in the trenches of the National Health Service in the Derby City Hospital in the Midlands of England treating coal miners and the artisans who crafted Royal Crown Derby china. This was during the winter of discontent in 1973 when the Heath government was collapsing, the miners were on strike, British Rail was on strike, and the National Health Service was facing major fiscal challenges. The experience taught me a lot about big government. I also had the opportunity in 1974 to spend a month in mission hospitals in northern New Guinea. New Guinea was in a transition phase between colonial government by Australia and independence. I worked with a fascinating mix of missionary zealots, kind and humane physician philanthropists, and lunatics. I learned much about human nature and, just as important, I learned about the challenges facing nongovernment organizations that provide care to indigenous populations, the challenge of education versus dependency. In Melbourne, Australia, 500 miles southeast of Adelaide (Figure 6), I undertook my general surgical training at the Royal Melbourne Hospital, one of the great academic institutions of Australian medicine, where I had the pleasure of working with Brian Buxton and Jim Tatoulis (Figure 7). I began my cardiothoracic training at the Melbourne Children's Hospital, to which D'Arcy Sutherland had been called in from Adelaide to resuscitate a badly ailing congenital cardiac program. D'Arcy began by recruiting the great surgical technician Dr Roger Mee (Figure 8). This was the first of many opportunities where I witnessed how fragile a congenital cardiac program can be and the care that is needed to build cohesion between surgeons, cardiologists, intensivists, anesthesiologists, and the entire health care team that makes up a congenital cardiac program.Figure 7Brian Buxton, MD (left), director of cardiothoracic surgery at the Austin Hospital, Melbourne, and James Tatoulis, MD (right), director of cardiothoracic surgery at the Royal Melbourne Hospital, Melbourne, Victoria, with whom the author trained at the Royal Melbourne Hospital.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Roger Mee, MD, at left, past director of the Royal Children's Hospital, Melbourne, Australia, with Fabio Sallum, MD, Milton Meier, MD, both of Brazil, and the author.View Large Image Figure ViewerDownload Hi-res image Download (PPT) I continued my journey eastward to Auckland, New Zealand, where I worked with the surgical master Sir Brian Barratt-Boyes and his dedicated team, including Alan Kerr at Green Lane Hospital (Figure 9). I was extremely saddened by the recent loss of Sir Brian (Figure 10) and extend my condolences to his wife, Sarah. Working in New Zealand allowed me to witness once again the risks inherent in a fully nationalized health system when a country runs into economic difficulty, as was the case in New Zealand in the early 1980s.Figure 10Sir Brian Barratt-Boyes. Used with permission from Dr Randolph Chitwood.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Brigham & Women's Hospital in Boston (Figure 11), the next stop on my journey, was a sharp contrast to the nationalized health care system of New Zealand. Dr Larry Cohn and Dr Jack Collins, as well as my peer, Richard Shemin, who went on to head up the Boston University Program, all became close friends and mentors and demonstrated the efficiency and superb high standards that the US health care system could achieve. I was particularly impressed to find that there was no distinction between private and public patients. In fact, this concept really did not exist in the United States, and in those days the nonprofit academic health care system in Boston was about as egalitarian as one could possibly hope for. Drs Cohn and Collins arranged for me to work at the Children's Hospital in Boston, where Aldo Castaneda and Bill Norwood (Figure 12) were in the process of building a great regional congenital heart program on the solid foundation laid by Robert Gross. They achieved this through innovation, courage, and persistence in the face of intense criticism. It was a hugely important experience for me to be a part of the development of the Norwood procedure for hypoplastic left heart syndrome and the neonatal arterial switch procedure. I learned a lot about how surgical programs can weather the challenges that arise with innovation. During my 22 years at the Boston Children's Hospital, I worked with many enormously talented individuals. One of my two senior partners, Dr John Mayer, whom I was fortunate to retain on staff after I became chief of the department in 1994, has made many contributions to congenital coding and reimbursement. Dr Pedro del Nido, whom I recruited from Pittsburgh, is currently chair of our AATS scientific and government relations committee and is helping to lead the defense against the contraction of funding for cardiothoracic surgical research. This work is vital because there is no question that many forces are at work threatening academic institutions and academic surgeons. It is the role of a professional association such as the AATS to advocate for academic surgeons and institutions to protect our mission of advancing the field and training the next generation of cardiothoracic surgeons. There is no question that the teaching of cardiothoracic surgery is a complex task (Figure 13). We teach through our personal example, through our mentoring in the operating room, and through the dissemination of new concepts, new techniques, and the introduction of new technology at meetings such as this. We teach through the writing of original journal articles and book chapters, through the editing of books and journals, and through peer review of publications such as the Journal of Thoracic and Cardiovascular Surgery. We must reward such activities by mechanisms such as the distinguished reviewer award recently introduced in the Journal of Thoracic and Cardiovascular Surgery. But associations such as the AATS cannot do it alone. We must work with the collaboration and cooperation of teaching institutions, which must continue to provide incentives and opportunities for adequate instruction of the next generation. This was an easy decision for institutions when there was no limit on the number of hours that a resident could work and reimbursement through the Medicare program was generous. However, the current total costs of training are now being carefully factored into the economic analysis of the productivity of clinicians. One of the other great challenges facing cardiothoracic surgical educators is the difficulty predicting the manpower needs for our specialty at the end of a very long training process. How many surgeons should we be training today? Like many of you in this auditorium, my surgical training extended over 9 years. What will our manpower needs be in 9 years' time? This is a remarkably difficult question to answer for a host of reasons, but it is a question that we are obliged to answer. Cardiothoracic training is still ultimately a mentorship, and there is a fundamental obligation on the part of the mentor to assist the trainee to have a productive and satisfying position at the end of the training process. For many years the AATS and the Society of Thoracic Surgeons have collaborated in intramural workforce studies. Recently, in addition, we have commissioned the American Association of Medical Colleges to undertake a review to try to help us understand the impact of the many external forces that are likely to influence our manpower needs. These factors include demographic shifts such as the aging of the US population as well as technical innovations in our own and other medical specialties. The relatively recent subspecialization of cardiothoracic surgery into adult cardiac, general thoracic, and congenital has undoubtedly complicated the projection of manpower needs (Figure 14). The percentage of female physicians within the specialty has remained less than 5%. This statistic unique to our specialty has become increasingly important as the percentage of female graduates from medical schools has risen to greater than 50%. If it is to be truly informative, the manpower study will need to look beyond the shores of the United States. All of us are working within an increasingly interconnected global society. Just look at some data that are of great importance to the financial health of this Association. More than 50% of attendees at this meeting over the past 10 years have been non-US physicians (Figure 15). In other words, this meeting would be half its size without the international attendees. The same shifts can be seen in the submission and acceptance of manuscripts for our Journal (Figure 16).Figure 16Manuscripts submitted to the Journal of Thoracic and Cardiovascular Surgery by region of origin, 2000 versus 2005.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The AATS has responded to the internationalization of this meeting and the Journal in several ways. One of the members of the Council is now appointed from among the international members. We thank Marko Turina for the superb job that he has done in this position. Last year, the Council voted to eliminate US citizenship requirements for new members. In fact, the membership committee has been charged with increasing the international representation among the membership. The conversion of the Journal to an electronic format that is available globally brings distant countries closer to us, such as Australia and New Zealand, where the journal previously arrived more than 2 months after publication. At this meeting, we have instituted a global session that will be held again this year on Wednesday morning, organized by Dr Philip Corcoran, the chief of cardiothoracic surgery at Walter Reed Medical Center in Washington, DC, with whom I have the pleasure of working. Although it is tempting to attribute the growth of the international participation in our meeting and Journal to their academic excellence alone, I believe there are other important factors at work. Despite its contraction in the United States, cardiothoracic surgery is expanding at a prodigious rate in many areas of the world, particularly in India and China. This is primarily a result of economic development in these and many other countries, development which is being fostered by economic globalization. We need to examine how globalization may affect the manpower needs of our specialty, both within the subspeciality areas and for cardiothoracic surgery as a whole. This analysis will also afford us the opportunity to appreciate how globalization is affecting global health overall and the relevance of those changes to us, not just as cardiothoracic surgeons but also as physicians and as members of the human race. There are many definitions of globalization, but all of them carry the sense that the world is becoming smaller and we are increasingly interconnected economically, socially, and culturally. The epidemic of severe acute respiratory syndrome (SARS) and the avian flu threat also remind us that health risks have been globalized. There is a tendency to perceive globalization as a totally new phenomenon, a recent consequence of the Internet, the digitization of data, and the establishment of a global hub-and-spoke air-transportation system. However, viewed from a greater distance, globalization is a continuum that has extended over millennia with the gradual breakdown in local tribalism as transportation and communication have evolved. New Guinea, as I learned when I was there, is a fascinating study of the consequences of difficult communication and transportation resulting from the dense and mountainous jungle terrain. The isolation of individual tribes has been associated with 400 unique languages among New Guinea tribes, which represents the densest concentration of diverse languages of any region of the globe. In contrast, international airline pilots have had to adopt English as a universal global language. There have been important tipping points in the progress of globalization. In fact, some would say that globalization began with the emergence of intercontinental travel by sail ship and the emergence of the capitalist world system in the 1500s. The industrial revolution and the harnessing of power in the 19th century are cited by others as the origins of globalization. The modern era of economic globalization, however, can be pinpointed with great accuracy both geographically and chronologically. Figure 17 shows the Mt Washington Hotel, nestled in the beautiful White Mountains of central New Hampshire not too far from my own New England home. In July 1944, representatives from the 44 allied nations of World War II, which was still in progress, sowed the seeds for the establishment of the World Bank, the International Monetary Fund, and the World Trade Organization. During the cold war years, these three institutions provided the economic armamentarium whereby Western countries pursued the objective of containing communism by providing loans to developing countries. After the fall of the Soviet Union, however, these organizations adopted a new agenda. The underlying goal has been to reduce global poverty and to improve economic opportunity and productivity throughout the Second and Third Worlds by opening markets, removing trade barriers, and through carefully monitored loans from the developed to the developing world. Supporters of globalization can produce powerful evidence that these goals are being achieved.1Bhagwati J. In defense of globalization. Oxford University Press, New York2004Google Scholar, 2Wolf M. Why globalization works. Yale University Press, New Haven2005Google Scholar However, there is another side to the story, as I will examine in a few minutes. First, however, let us look at the health consequences of globalization and what these mean for us as cardiothoracic surgeons. In the early 1990s, the World Bank commissioned a projected titled The Global Burden of Disease.3Murray C.J.L. Lopez A.D. Evidence-based health policy—lessons from the Global Burden of Disease study.Science. 1996; 274: 740-743Crossref PubMed Scopus (1750) Google Scholar This was performed in conjunction with the Harvard School of Public Health and the World Health Organization, the coordinating authority for international public health established by the United Nations in 1948. One important outcome of this study was the development of a new metric, the disability-adjusted life year, which allows assessment of the effect of disease not only on lifespan but also on health span. In essence, a life can be shortened not only by death but also by chronic disability. Figure 18 demonstrates that in 1990, communicable diseases such as respiratory infections remained the most common global cause of death and chronic ill health. However, projections by this study suggest that by 2020 ischemic heart disease will have become the number 1 disease entity, nearly doubling in less than 30 years. Health losses from cancer are also projected to nearly double over the same time frame. Economic development carries with it the consequences of an aging population and the hazards of smoking and high fat, high calorie diets.4Magee M. Health politics: power, populism and health. Spencer Books, Bronxville [NY]2005Google Scholar Economic progress in the developing world has been accompanied by the replacement of the traditional diet rich in fruit and vegetables by a diet rich in calories provided by animal fats and lower in complex carbohydrates. It has been reflected in a rapid rise of urban obesity. When I first started visiting China in the early 1980s, there were no obese children. There was only one heavy person at our hospital and that was the cook, who determined that I was going to look like her by the end of our visit with a wonderful diet of dumplings. However, the prevalence of obesity in urban children in China aged 2 to 6 years has increased from 1.5% in 1989 to 12.6% in 1997.5Harris R. Seid M. Globalization and health. Brill Academic Publishers, Boston2004: 223Google Scholar Cooking in the developing world has been altered by the availability of microwave ovens and cheap prepared meals with high fat and caloric content. In the United States, the fast food industry spent 3 billion dollars on television advertising in the year 2000. In the same year, the National Cancer Institute's "5 a day" program, which encourages the consumption of fruits and vegetables to prevent cancer and other diseases, spent 1 million dollars.6Stieger M. Globalization: a very short introduction. Oxford University Press, New York2003: 72Google Scholar There is a tendency to focus any discussion of the aging of the general population of the United States on the baby boom generation, the population bulge that will reach 65 in just 5 years in 2011. However, the situation is significantly compounded by the dramatic increase in life expectancy that has occurred over the past 50 years (Figure 19). In the year 2000, Americans enjoyed a life expectancy of almost 77 years. One hundred years ago life expectancy was close to 50 years. Today, individuals who reach age 65 can anticipate a life expectancy of 81 for men and 84 for women.4Magee M. Health politics: power, populism and health. Spencer Books, Bronxville [NY]2005Google Scholar And for those who live to age 65, the top two causes of death are heart disease and cancer, followed by stroke, emphysema, and pneumonia. All these conditions share a common risk factor: tobacco. Trends in the use of tobacco will have important implications for the burden of cardiovascular and thoracic disease that we will face in the coming years. Although tobacco use in the developed world is declining slowly by about 0.5%/year, tobacco use in the developing world is rising at nearly 3.5%/year (Figure 20).4Magee M. Health politics: power, populism and health. Spencer Books, Bronxville [NY]2005Google Scholar, 5Harris R. Seid M. Globalization and health. Brill Academic Publishers, Boston2004: 223Google Scholar Today there are more than 1 billion smokers around the globe with numbers projected to rise by more than 30% in the next 20 years. And although the large American and British tobacco multinational companies take much of the blame for the rapid current expansion of smoking in the developing world, the fact is that China is overwhelmingly the largest producer of tobacco, producing 36% of the world's cigarettes in contrast to 11% produced by the United States. In fact, China and its state-run tobacco monopoly produce more tobacco than the next 6 largest producers combined.4Magee M. Health politics: power, populism and health. Spencer Books, Bronxville [NY]2005Google Scholar How will these changing global demographics and practices affect the disease entities most relevant to cardiothoracic surgeons? It is no news to this audience that lung cancer, particularly in American women, has already reached epidemic proportions. Between 1930 and 1997 the death rate from lung cancer among American women increased 6 times. In 2003, there were 20,000 more deaths from lung cancer than from breast cancer among women (Figure 21).4Magee M. Health politics: power, populism and health. Spencer Books, Bronxville [NY]2005Google Scholar Unfortunately, efforts to reduce smoking rates have been less successful with women than with men. Outside the United States, women are responding to aggressive targeted marketing and joining the ranks of smokers every day. In Japan, smoking among women has doubled over a recent 5-year period from 9% to 18%.4Magee M. Health politics: power, populism and health. Spencer Books, Bronxville [NY]2005Google Scholar The dramatic declines in death rates from heart attack and stroke in the United States over the past 50 years have lulled us into a state of complacency and blinded us to a storm that is gathering just over the horizon. The convergence of risk factors, particularly obesity, diabetes, and physical inactivity in the United States and tobacco use, dietary changes, and increased life expectancy globally without question will result in a substantial increase in the global burden of cardiovascular disease. Despite regional variations in environmental factors and genetic makeup, the incidence of congenital heart disease around the world remains consistently at approximately 0.8% of live births, thereby making it the most common major congenital abnormality. Despite predictions that improved ultrasound methods for fetal diagnosis would result in increased rates of pregnancy termination, the reality is that within the United States and most developed countries fetal diagnosis has not had a large impact on the incidence of congenital heart disease. Widespread use of echocardiography, in fact, has resulted in earlier and more complete diagnosis of salvageable heart problems in children. Earlier recognition of congenital heart disease is eliminating the scourge of pulmonary vascular obstructive disease, which is making surgery available for a much greater percentage of the world's children with congenital heart disease than in the past. And the cumulative population of adults with congenital heart disease is also increasing the workload for many congenital heart programs. Perhaps ultimately an improved understanding of the genetic basis of congenital heart disease will eliminate the specialty entirely, but at this point such an eventuality remains beyond the horizon. How will an increased global burden of cardiovascular disease and cancer affect the manpower needs of our specialty? There is no international organization that has the resources to estimate the total number of cardiothoracic surg