Reflections from the Past and Thoughts for the Future

The beginning of the 21st century is both an exciting and a trying time in which to practice cardiothoracic surgery. Major breakthroughs are occurring on an almost daily basis. Robotics and other technical innovations are increasingly being incorporated into cardiovascular practice. Molecular biology is making its way into our specialty, and gene therapy for atherosclerotic occlusive disease may become practical in the not-too-distant future. Other promising options, which are still on the far clinical horizon, include the use of “designer” tissues grown from embryonic stem cells and the use of xenograft organs. Meanwhile, despite today's climate of unprecedented innovation, increased governmental intervention and regulation are complicating the practice of our specialty.

In a recent editorial titled “Dr. Discontent,” Dr. Jerome Kassirer ¹ stated that many American doctors are unhappy with the quality of their professional lives. They are frustrated by loss of control over clinical decisions and by financial incentives that strain their professional principles. Their time is being increasingly consumed by meaningless, intrusive paperwork, by telephone calls to gynecologists for approval of cardiothoracic operations, and by complex business activities mandated by a fragmented health care system. Insurers are denying claims, reducing fees without warning, and making physicians assume the expense of complying with stricter regulations. In response to these stresses, many physicians are selling their practices and joining multispecialty groups, hospital networks, or physician management companies. Others are seeking advanced degrees in medical or business administration and are embarking on alternative, nonclinical careers.

We all long for the halcyon days of the 1960s and 70s, which were the most productive decades ever for thoracic surgeons. Prosthetic heart valve implants, coronary artery bypasses, and cardiac transplants became commonplace as government money poured into medical research and into Medicare's system of cost-plus reimbursement. That program, proposed by President Truman in the 1940s and passed by President Johnson in 1965, rapidly accelerated the introduction of new technologies and procedures. However, in the 1980s, rapid growth in national health care expenditures caused the government to impose constraints on Medicare spending, beginning with hospital costs. In 1982, Congress eliminated cost-based payment and substituted a prospective pricing scheme, by which hospitals were paid on a per-case basis, as determined by a diagnosis-related group. With fewer, sicker patients occupying hospital beds, hospitals' operating margins began to diminish, and costs were shifted to private insurers. These trends fueled the public's growing dissatisfaction with health care delivery and promoted the development of managed care. Dr. Richard Anderson ² aptly summed up this evolution when he described the 1960s as a decade of innovation in thoracic surgery, the 70s as a decade of clinical expansion, the 80s as a decade of increasing restraint, and the 1990s as a decade of ongoing dichotomy and paradox.

Today, as incentives continue to be based on “less” instead of “more,” surgery is losing its status as a free-market model. Sophisticated diagnostic and therapeutic modalities are available for clinical application, but providers are increasingly constrained by those who pay the bills. At the same time, owing to a progressive deterioration in the doctor/patient relationship, physicians must practice defensive medicine to protect themselves from litigation. They are also being faced with a growing tide of aging Americans who comprise the postwar generation of “baby boomers.” This aging of the population will continue for the next few decades. Today, approximately 20% of the population is more than 65 years old; however, in 2030, the elderly will account for more than 31% of the population. ³

Between 1980 and 1990, our nation's total health care expenditure increased from about 9% of the gross domestic product (GDP) to approximately 12%. By 2005, health care will account for 18% of the GDP, or more than $2 trillion per year. ³ As medical inflation has continued to accelerate and attempts to control it have increased, thoracic surgeons have been at the forefront of fee cuts. Too often, we have resembled petrified “deer in the headlights.” In 1971, Dr. Denton Cooley ⁴ wrote, “The doctor is a favorite target for critics of all persuasions. He's reproached for his indifference to patient demands for special attention, faulted for his reluctance to attempt treatment in the home, and denounced for his tendency to treat seemingly minor ailments in the hospital. His avariciousness is insinuated and his income, reported to be among the highest of all professional groups, is deplored and resented.” Indeed, it would seem that the government is conveniently inclined to view the practitioner as unscrupulous and conniving in pursuing payment through the Medicare program. Physicians are caught in the middle of the government's war on Medicare and Medicaid fraud. For an unlucky minority of practitioners, that has meant office raids, complete with federal seizure of medical records, computer files, and other data. In this climate, a general pessimism about the future of medicine seems to prevail.

We cannot claim that our leaders failed to warn us about the current situation. In the early 1980s, in an address to the Western Thoracic Surgical Association, Dr. Robert Jamplis ⁵ stated that “a revolution is occurring in health care in the United States, and … [it] will profoundly affect the lives of all doctors of medicine … thoracic surgeons in particular.” Jamplis cited the continually increasing cost of medical technology, the aging of the American population, and the need to practice defensive medicine as some of the reasons for this revolution. He concluded, “Our greatest failure has been our devotion to the status quo. No matter how nostalgic we feel about it, it is no longer a viable entity. I truly believe we now have only one more chance to lead the revolution or be consumed by it—take charge or be taken over.”

How can thoracic surgeons embrace change and avoid being consumed by it? First, we must return to our core belief that practicing medicine is a great privilege and that the essence of that privilege lies in taking care of our patients. We must take pride in our work, maintain our self respect, and promote the dignity of our profession.

I believe that it is appropriate for us to look to business leaders for inspiration. In their book titled Built to Last: Successful Habits of Visionary Companies, ⁶ Professors Collins and Porras, of Stanford University, identified the characteristics of 18 corporations that are widely regarded as the most outstanding businesses in the United States. The authors hypothesized that, if a leader is successful at creating a great company, great products and great profits will naturally follow. This hypothesis has been proved correct. Instead of sitting by timidly and warily in our hospitals and medical centers, we need to work to improve these institutions, because it is only the best health care organizations that can survive in today's climate. The authors of Built to Last say that it is “[b]etter to understand who you are than where you are going—for where you're going will always change. It is a lesson as relevant to individuals as to visionary companies.” The companies described in the book believed that the best way to succeed in the market was to get better at what they did. Therefore, they competed vigorously and constantly against themselves, striving to surpass their own internal benchmarks. Likewise, in a 1998 address presented to the American Association for Thoracic Surgery, Dr. Floyd Loop ⁷ said, “The best surgeons … compete mainly with themselves to get better every year. Try to be better than yourself. It is a lot more stimulating and rewarding than competing with colleagues.”

Because our profession is in the business of results, ^7,8 we need strong leadership to guarantee quality and to assure that medicine does not simply degenerate into a commodity. In 1984, Dr. Cooley ⁴ said, “There's hardly anything in the world that some man cannot make a little worse and sell a little cheaper, and the people who consider price only are this man's lawful prey—we must not compromise our traditional role as physicians—our primary focus must remain the quality of health care.” Leadership comes easily to most thoracic surgeons, who are problem solvers and decision makers by nature and tradition. In the new era, we may be making difficult decisions regarding the value and ethics of medical care delivery rather than devising ingenious solutions to long-standing clinical problems. An outstanding example of visionary leadership has been set by the Society of Thoracic Surgeons (STS), which, over the last 2 decades, has established a database of cardiac and thoracic surgical procedures that has become a gold standard. The STS has also worked with governmental agencies to establish more effective methods for evaluating and controlling the technology related to our specialty.

In addition, our profession needs to renew its courage, which has recently been in a decline. Symptoms of this decline include apathy, a tendency toward self-preservation, and a fear of sticking one's neck out. Whereas our surgical forebears boldly entered the operating room to pioneer new procedures and solve complex operative problems, today's surgeons tend to retreat to the operating room to perform well-established operations and to seek respite from the business aspects of surgical practice. They may say, “Please, just let me operate. Don't bother me about practice overhead, clinical pathways, and managed-care contract relations.” However, governmental and economic considerations will have an ever more pervasive influence on our medical practices, especially as the percentage of older persons increases. Instead of retreating within our individual practices, we need to renew our commitment to our specialty and to medicine in general. Obviously, it is easier for physicians to acquire insights into health care business practices than for medical administrators to understand the nuances of health care delivery. Therefore, we must have the discipline to learn the elements of health policy and business. We must train ourselves to function within integrated health organizations at all levels, from the delivery of bedside care to the resolution of payment issues and ethical dilemmas.

As Dr. Loop ⁷ has pointed out, sooner or later we will all be patients. When that time comes, we will not want politicians, lay health care administrators, and lawyers to dictate our treatment. We will want to be treated by a professionally managed, physician-directed, patient-focused health care organization that delivers the best possible quality for the lowest justifiable price.

Across the centuries, Hippocrates reminds us that ”[l]ife is short, the art of medicine long, time is fleeting; experience fallible, decisions difficult.” ⁹ We do not live in the same world as our surgical forebears, but we can adapt to current circumstances—or perhaps even change them—by letting go of outworn traditions while continuing to uphold the highest values of our profession.