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Reflections on a Career in Cardiothoracic Surgery: Maintaining Humanism in a Changing Environment

2019; Elsevier BV; Volume: 109; Issue: 3 Linguagem: Inglês

10.1016/j.athoracsur.2019.09.067

1552-6259

Kevin Accola,

History of Medical Practice

As I consider this a profound honor and privilege to stand before you today as the Southern Thoracic Surgical Association’s (STSA’s) 65th President (Figure 1). In preparation for this address I pondered long and hard regarding “what can I say to such a distinguished group of colleagues, mentors, and longtime friends?” Hopefully, something that may intrigue, perhaps create some reflection, and possibly leave a lasting impact. I asked some previous STSA presidents and close friends, who have been mentors for many years, for suggestions on how they would proceed. Joe Coselli, the STSA’s 58th President, suggested I pick a general topic, such as leadership, and then expand on it. I also asked Bill Baumgartner, the STSA’s 46th President, and John Hammon, the STSA’s 55th President, who both suggested that I choose a topic that interests me and then expand on it. I then asked my close friend and longtime STSA member Alan Speirs, who echoed the prior advisors by suggesting that it’s appropriate to select any topic that is of interest to me. Finally, I went to the mountain top of opinions, Gus Mavroudis, academician, philosopher, superb orator, and the STSA’s 49th President. In quick order he also stressed that I choose any topic of interest, “as long as you don’t speak too long!!!” Professor Mavroudis, I will try to adhere to your advice. In preparation for this presentation I found myself reflecting on my career in cardiothoracic surgery, realizing how much of a privilege and honor it has been. My thoughts came back to the challenge of maintaining humanistic values or qualities in a rapidly changing healthcare environment. As I prepared for this address I did some soul searching, reflecting on a busy and active private practice in cardiothoracic surgery. Perhaps too much as I didn’t want this to be a “Jerry McGuire” moment but rather a contemplative time of both personal evaluation and professional observation of my own training and career, as well as the new challenges as our profession adapts to the future. When I finished I had numerous pages of insights which I felt were important to me. So I narrowed these down to some thoughts I would like to share with you this morning. They come from a perspective of maintaining our values and qualities birthed from years of medical school and training. But yes, and a big yes, of how our foundational perspective has changed and how we must evolve with our rapidly changing environment. And, perhaps most importantly, this includes what impact we may have on the future of our profession. It’s been said that history repeats itself, though I truly believe we would all agree, not necessarily in healthcare. Charles Darwin suggested many years ago “It’s not the strongest of the species that survives nor the most intelligent, but the one most responsive to change” (Figure 2). Nearly 2 centuries later Thomas Friedman, the noted New York Times columnist and author of “The World is Flat,” describes how internet and “cloud-based information storage technologies” have forever altered and changed society as we know it.1Friedman T.L. The World Is Flat: A Brief History of the Twenty-First Century. Farrar, Straus, and Giroux, New York, NY2005Google Scholar This astonishing growth of information technologies is now clearly evident in all aspects of our existence. In our particular vocation of cardiothoracic surgery, the sea change in internet availability has altered the training of residents and students in a way that makes it unrecognizable from the training many of us underwent. Memorizing Goodman and Gillman’s The Pharmacological Basis of Therapeutics textbook has been replaced by internet-based resources at the touch of a button, with far more detail than human memory could ever recall. Most of us would agree that the explosion of information and the rapid availability of it through cloud access is an astonishing success. But, those of us who have lived through this revolution can also point to how an over-reliance on this information may contribute to less humanistic bedside care for our patients. As I walk the halls of my hospital today, the students and residents all hover over computers and electronic notebooks, staring at the screens and furiously typing, nearly always with their backs to the patient. Is internet technology a disruptive force? Certainly, but also just as certain it is not necessarily a bad thing. Would any of us want to exchange our smartphones back to carrying a beeper and a pocket full of quarters? I didn't think so. But what I would like to focus on this morning is not the good, bad, or the ugly of many of these technologic developments or how they have affected what we do as it pertains to cardiothoracic surgery, as I do believe the positives exponentially outweigh the negatives. It is my belief that we must focus diligently on maintaining the “human element” and, yes, to coin a cliché, “the art of medicine” in healthcare. Gone are many of the physical examination skills once taught (Figure 3), as new and quite exact evolving diagnostic entities have superseded the “human capabilities” previously employed to address most medical illnesses. Is this a good thing? Unequivocally yes to a large degree. For example, I would like my car hooked up to a computer to “diagnose” problems that can easily be fixed. I really don't mind if my car is a data screen and a “problem list” is expelled from a computer. I just want to get it fixed. But, are we trending this way with our delivery of healthcare? I am not sure society’s expectations will entirely align with such a process within healthcare. Limited patient interaction time has been interposed and interferes with “cognitive time” at a computer screen. Even in the form of documentation of this time spent or billing purposes or level of care provided. So, some thoughts I will share with you this morning on maintaining humanistic qualities of our profession and, yes, how our profession must have a paradigm shift regarding these “qualities” we have held in such high regard. I also hope to share perspectives I believe are necessary regarding current and future leaders and some specific educational initiatives that can foster a sustainable culture for our current healthcare environment. Humanism has been defined as “any system or mode of thought or action in which human interests, values, and dignity predominate.” Dr David Cossman, a senior vascular surgeon at Cedars Sinai in Los Angeles and noted essayist who provides editorials for General Surgical News, wrote, “Becoming and being a physician transforms us all. The interpersonal dynamic between doctor and patient is complex and unique. Other people’s pain and suffering, death, and disease do not exist to broaden our sensibilities, but they do. Confronting them forces us to understand that we need to learn to comfort and console as much as to cut and sew, and the total commitment and sacrifice are required if we are to succeed. The interpersonal dynamic between doctor and patient is complex and unique.”2Cossman DV. A higher calling no longer. General Surgery News. August 19, 2018. Available at: https://www.generalsurgerynews.com/Opinions-and-Letters/Article/01-12/A-Higher-Calling-No-Longer/52369. Accessed September 10, 2019.Google Scholar Dr Cossman is, in essence, defining the “art of medicine.” He is also espousing a strong defense of maintaining the compassion, or the human element, in medicine that has made it the unique profession among all others. Dr John Mayer, in his memorable Society of Thoracic Surgeons presidential address from 2008, discussed the emphasis of what being a member of a “profession” entails.5Mayer J.E. Is there a role for the medical profession in solving the problems of the American health care system?.Ann Thorac Surg. 2009; 87: 1655-1661Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar To quote Dr Mayer, “Throughout this year, I have tried to view every issue from the perspective of what will be good for our patients and what will be good for our profession. I want to emphasize that word ‘profession’, a common heritage that binds all of us together, but a concept that is incompletely understood and easily forgotten in the atmosphere of the financial and societal pressures in which American medicine now finds itself. I would like to focus on what it means to be a member of the medical profession and to provide a conceptual framework from which to understand some of the challenges and concerns we all have. From this perspective, I believe some solutions to the problems we face can emerge.” Dr Mayer went on to discuss our societal obligation to do the right thing as our healthcare process undergoes “economic correction.” If I may add to this, we must do the “right thing” in regard to the influence of technology as it pertains to patient care and interaction. I believe we all want to do that philosophically, but in an increasing virtual healthcare environment electronic medical records, information technologies, time constraints, cost and value awareness, best practice algorithmic protocols, often times our backs are to the patient, or the “covered lives” so to speak. As physicians we must not all be placed into a “common provider” role and consider our patients as “covered lives,” “customers,” or “clients.” Most importantly we must not lose perspective of those for which we are responsible. Surgical dogma has been forced aside in favor of a more legitimate and standardized, evidence-based medicine and best practice protocols approach to patient care. Additionally new technologies have surfaced that were once distant visionary ideas that have resulted in entirely new strategies and paradigms for surgical intervention. Lewis Thomas, physician, scientist, and author in his book, The Youngest Scientist, Notes of a Medicine-Watcher,3Thomas L.T. The Youngest Science: Notes From a Medicine Watcher. Viking Press, New York, NY1983Google Scholar describes his reflections, observations, and notes beginning as an intern in the 1930s and throughout his career as a world-renowned researcher. Nearly 40 years ago Thomas stated, “The physician has the same obligations that he or she carried, overworked and often despairingly fifty years ago, but now with any number of technical maneuvers to be undertaken quickly and with precision. The hospitalized patient often feels, for a time, like a working part of an immense, automated apparatus. The patient is admitted and discharged by batteries of computers, sometimes without even learning the doctor’s names. Many patients go home speedily, in good health, cured of their diseases. If I were a medical student or an intern, just getting ready to begin, I would be more worried about this aspect of my profession. I would be apprehensive that my real job, taking care of sick people, might soon be taken away, leaving me with the quite different occupation of looking after machines.” Dr Thomas warned us about the loss of personalization in medicine long before personal computers were created. Consider now the current practice of morning “multidisciplinary rounds.” Certainly there is a positive attribute to this team approach and collective effort, but does this distract from the “why” we do what we do and create layers between physicians and our staff with the patient? Our healthcare environment is rapidly changing as wel, in regard to value-based initiatives and will continue to do so and in an incredibly and exponentially rapid pace. The internet, telemedicine, video conferencing, and now the “Amazon effect” are a few examples of this idea. Innovative technologies requiring new skills much different from what we were trained to do have developed a vast array of diagnostic capabilities. Despite the overwhelming flood of available information physicians have at their fingertips, all these modern resources overtly or subtly decrease personal interaction with our patients. The amazing and incredible impact of new technologies has altered how we approach and look at our patients. An example is the development of percutaneous technologies. Who could have imagined the impact these have had on our approach to surgical treatment strategies of cardiac disease processes? Disruptive technology began years ago with our cardiology colleagues and the advent of coronary balloon angioplasty with subsequent coronary artery stent placement. Recently, for example, in cardiac surgery the implementation of percutaneous aortic valve replacements, mitral repair techniques, and aortic vascular have been disruptive forces. One of our past presidents, Mike Mack, Michael Reardon, and numerous other surgical colleagues courageously took a lead role in the advancement of the transcatheter aortic valve replacement (TAVR) technology. Even though there were many initial nay-sayers, in just a few short years this technology has certainly revolutionized the way we approach and treat aortic valvular disease. I am thankful surgeons were instrumental in this collaborative developmental process. But let’s dissect the TAVR technology in more detail. At our institution we have performed over 1400 procedures, and many patients who would have not had a chance at the treatment of their aortic stenosis or had been at considerable risk are back to a quality of life within days because of this technologic advancement. Valve longevity in TAVR procedures is yet in question. But what are we learning? When mall orientation of the leaflets occurs, the possibility of the leaflets not being “washed” in a normal manner creates several concerns such as thrombosis, early and late perivalvular leaks, and early structural valve deterioration. What impact do these “new” problems entail and how are they to be dealt with? Would these degrees of perivalvular leaks be accepted by our surgical mentors years ago, or would this then have been considered a “failure” in treatment? As new technologies progress, new paradigms will certainly develop and require consideration and innovation to resolve and treat these unforeseen but now recognized complications. While I would encourage our young colleagues not to get rid of their sternal saws and retractors quite yet, how our profession trains our future cardiac surgeons must be altered, as well as how our future surgeons obtain and sustain the skills of conventional, open cardiac surgical procedures. Pulitzer award-winning author and physician, Siddhartha Mukherjee, in his book, The Laws of Medicine: Field Notes from an Uncertain Science,4Mukherjee S The Laws of Medicine: Field Notes From an Uncertain Science. TED Books, Simon and Schuster, New York, NY2015Google Scholar stated, “The 'Laws of Medicine' are really laws of uncertainty, imprecision, and incompleteness. They apply equally to all disciplines of knowledge where these forces come into play. They are laws of imperfection.” Dr Mukherjee further explains his views into three general laws (Figure 4):•Law One: A strong intuition is much more powerful than a weak test. Intuition? Intuition comes from an innate and immediate understanding of the surrounding circumstances relative to experience. Perhaps the old adage still prevails to a degree, “Good judgment comes from experience, and experience comes from bad judgment.”•Law Two: Dr Mukherjee’s Second Law teaches us that “normals” teach us rules; “outliers” teach us laws. Evidenced-based protocols will have outliers, who will suffer harm or receive inappropriate treatment if clinical intuition is not a cognizant variable.•Law Three: For every perfect medical experiment, there is a perfect “human” bias. There will always be a bias due to our human element. Cognitive dissonance occurs, and unneeded tests are done and possibly something is missed or, just as critical, overtreated. As an example, consider the seasoned and experienced clinicians. They have often developed a sixth sense of intuition, which may utilize some element of bias, that involves looking at patients as individuals and incorporating the “humanistic element” in patient care, irrespective of a care map algorithm treatment strategy. I do believe care maps and best practice protocols have a place in developing standardization of care as guidelines. But where in our clinical best practice models or algorithms do these “laws” Dr Mukherjee has proposed come into play? Not only with physicians but our healthcare teams, particularly our bedside nurses and physician assistants, who many now feel have been placed into a role of “data entry” individuals following algorithms and checking boxes. Many of these bright young nurses are now leaving bedside care to go onto more advanced patient care options. Our healthcare environment will not get easier and will definitely become more complicated, animated, virtual, and transparent. This may lead to increased frustration of those individuals on the “frontlines” of patient care. This includes those who are tasked with implementing an explosion of information while comforting a sick patient who is totally reliant on a stranger’s judgment. Physicians, as a whole, are incredibly motivated and hardworking individuals, but never has there been more frustration related to physicians’ daily activities of providing patient care. This has impacted our relationships with patients and, collegially, with each other. This is a reality that must be addressed, and avoidance solutions must be developed. We must encourage and allow our physician colleagues to reach out and help each other. We must also be encouraged to fulfill our “calling” if you will of the “why” we went into medicine in the first place: the personal patient interaction and relationship with our patients, instead of an immensely automated daily working process. Dr Wayne Sotile and his wife Mary have interacted with over 14,000 physicians over the past 35 years. Dr Sotile will be speaking Saturday morning on “physician resilience” in the postgraduate course. I am hopeful all of you will be able to attend as he will address some of these issues. Also quite disturbing is the fact there is an alarming rate of physician suicide, as nearly 1 physician daily “taps out” and commits suicide. The term “physician burnout” is increasing, but it has been clarified, not as a direct result of being overworked, taking care of patients, or being “tired.” More as a result of the “other stuff,” which includes increasing frustrations imposed on physicians from payer demands, institutional policies, governmental regulation, and increased documentation requirements. All of these also make it difficult to fulfill his or her obligation to patient care in the manner in which he or she was trained while lacking in patient “humanistic interaction.” Two initiatives I believe we must do to ensure our profession’s values are kept intact are an ongoing emphasis on Leadership and Education. A quote attributed to Abraham Lincoln reads, “The best way to predict the future… is to create it.” There has never been a more important time in healthcare for physicians to become leaders. Not in a cliché manner or by obtaining a “title,” as leadership is not merely a position or having a corner office. Instead making a personal choice or decision to look after those around us in a positive manner; to make them feel safe to speak up when they discover a problem or a concern. As leaders we must create working environments that foster safety while also ensuring humanistic values and safety in the care of our patients. Corporatization of healthcare is everywhere and rapidly expanding. Physicians must be involved in administrative positions while remaining clinically active, or we can simply become a commodity and rightly so accept the title of “provider of services” as opposed to the distinguished and long pathway in obtaining the title of a physician. We must remain engaged clinically in patient care while assuming our roles of active participants as physician leaders if we aim to maintain patient-centric focused values in our hospital systems. At Florida Hospital (now AdventHealth, Orlando) where I have practiced the past 26 years, a Physician Leadership Development program has been initiated and generously supported by our hospital administration. The course is directed and led by retired Lieutenant General Mark Hertling. This program has been a wonderfully collaborative effort for physicians and executive hospital administration. It is an intense yearlong voluntary program of extensive reading, didactic lectures, and group sessions designed primarily to develop proactive leadership using examples of historic military leaders and campaigns. It culminates in a group visit to Gettysburg, Pennsylvania where a detailed battle site tour describes how many decisions lead to the ultimate outcome of the battle. Each participant is required to study 1 of the major battle characters prior to the visit and is required to role play that character during the re-enactment of the battle. This group exercise becomes a memorable event, all in an effort to understand how decisions—good and bad—impacted the battle’s final outcome. This year-long program is focused on developing physician leadership capabilities and creates a common dialect between the hospital administration and physicians. Now entering its seventh year, there have been 245 physician graduates. This course was a fascinating experience for me, and I endorse these types of programs not only to expand the physician’s perspective on the importance of disciplined decision-making but also providing a broader hospital administrator understanding of the physician’s perspective. Unlike history I believe the practice of medicine, which many of us more senior members grew up and matured in, will ever repeat itself. But with appropriate leadership and foresight, hopefully the values and positive aspects will prevail and be instilled in our future generations. This will require leadership not only day-to-day, dusty boots on the ground, but from physician administrative levels, those who are continuing to be clinically active. My final remarks highlight our need to encourage an enlightened and focused approach to ongoing education. Indeed new paradigms are necessary if the humanistic qualities of our profession are going to prevail and be sustained. I am certainly not going to get into the various pathways or processes of educating cardiothoracic surgeons in the current era, as that has become complicated and is beyond the scope of this address. Dr Baumgartner, Dr Calhoon, and Dr Kern are going to touch on some of those aspects during this year’s Kent Trinkle Education lecture. I do believe it is imperative that we be very mindful of how we project ourselves to our young colleagues, residents, nursing students, and the numerous healthcare trainees we encounter daily, as there are infinite educational opportunities available. Maybe you believe that because you have no medical students or residents you are not directly involved in education. The reality is we all are involved in education in a representative manner of our profession. Being a positive influence on our nursing staff and younger surgical colleagues is imperative, and the fact is they may be taking care of us someday. Certainly we all have an opinion on what’s wrong with medicine today. In preparation for this address I discussed and collected many of our physician colleagues’ comments and concerns in our hospital and around the country to understand their thoughts on where we have gone wrong and where we have gotten it right with little verbal interjection. Which is sometimes difficult for me to do if you ask my partners and certainly my wife. But during that time I made a list of all the things discussed. Nearly all were negative. With all the negatives I’m pressed to ask why would any bright young enthusiastic mind want to pursue this notable career? I am always impressed with the children of physicians who pursue medicine. Possibly their mother or father “physician” had this figured out and “did it right.” How did these parent-physicians positively influence their children? What can we learn from them? How can we influence the positive and necessary charges our specialty has taken without berating our profession's future colleagues with depressing and woeful despair for “how it used to be?” In my humble opinion the answer is progressive education and passionate mentorship in an enthusiastic, positive manner as an example of the “why” we went into medicine as a profession. Clinically how we look at disease processes has been forever altered and requires a paradigm shift not only for our new trainees but those of us active in cardiothoracic surgery practices. While we adapt to create new optimal treatment strategies in regard to technologic advancements, we have to simultaneously promote new methods of training, accepting that many of the old surgical dogmas of our training are on “life support” or have “expired.” We must focus on effective, relatable, and continuous education styles that emphasize these new perspectives and treatment strategies that will eventually become accepted standards of care. Again highlighting our TAVR experience, I have learned first-hand the importance of collegial and collaborative operative practice with my cardiology colleagues. There is no imposed “You do X and I will do Y” but a combined, multidisciplinary effort implemented as a shared learning response. This collegial interactive experience has profoundly changed my understanding of our cardiology colleagues’ perspectives and similarly for them. It is a model of professional collaboration that has forged a strong partnership with mutual respect for skills and experience. This sharing of experience and intuition has led to very high-quality outcomes in a progressive manner among our entire TAVR team members. This is a model for future generations of cardiothoracic trainees, but we must not lose sight of our traditional, lifesaving surgery technical training, as it will continue to be needed for generations to come. We cannot let the pendulum swing too far, as I believe we need our residents to be trained as “surgeons of cardiothoracic disease processes,” as we will always need this expertise. Knowing what is before them in complexity and skill requirements, I do not believe that shortening or condensing the training process is the answer. We also must be a positive influence on our younger students and staff. Similarly to what happened with our children and which almost all attest to, they really do watch what we do and listen to what we say. I would challenge each of us to notice ourselves and pay attention to our language, body mannerisms, and attitudes this next week. Are we presenting ourselves and our profession in a positive light or as a negative, possibly burned out frustrated curmudgeon? Our actions, words, and attitudes most certainly are contributing in an “educational manner” to the milieu of our future physicians. Those who will replace us as our legacy determining the “health” of our profession and, again, as well as those who will be taking care of us someday! So I challenge each of us to walk our talk in education daily. Be an example for our young individuals and colleagues pursuing medicine and healthcare. Not a deterrent to the bright future of those aspiring to become physicians, particularly possibly future cardiothoracic surgeons. In conclusion we do have an incredible responsibility, as well as opportunity, to provide an impact on the delivery and progression of changes in healthcare in general, in particular cardiothoracic surgery. We must focus on healthcare as opposed to letting us be corralled into silos of “illness care” with dedicated algorithms of treatment strategies. We must be committed to our role in our profession as physician-surgeons, not merely “providers.” History may or may not repeat itself in regard to operations, treatment strategies, or the surgical training environment in which many of us experienced. But hopefully as future physicians look back on our time here, they will be relieved and content that the humanistic foundational qualities of our profession were well preserved, remaining intact by our proactive educational initiatives, leadership displayed, and insistence on preserving humanistic qualities while caring for our patients. We are the curators of the past, examples of the present, and creators of the future. Let us not relegate this privilege and responsibility to our “system” or current circumstances but rather enthusiastically embrace and uphold this opportunity to promote it. As was quoted earlier, the best way to predict the future is to participate in creating it. In closing, again I am honored and humbled for the privilege to have been the president of such a wonderful association this past year and I sincerely thank you. The author would like to acknowledge and thank Clay Burnett, MD, and Frank J. Fiorito for their editing and technical assistance.