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STS 50th Anniversary

Looking Back, Moving Forward


Walter H. Merrill, MD, Editor – June 2013

ALMANAC

Consider these notable events that occurred in the years these Presidential Addresses took place.

1998

On September 4, Google is founded by Larry Page and Sergey Brin.

1999

After being impeached by the House of Representatives in December 1998 on counts of perjury and obstruction of justice, US President Bill Clinton is acquitted on February 12 by the Senate.

On April 20, teenagers Eric Harris and Dylan Klebold killed 12 students, 1 teacher, and themselves in the Columbine High School massacre.

2000

On December 12, the US Supreme Court stopped the Florida presidential recount, effectively giving the state, and the Presidency, to George W. Bush.

“Study the past if you would divine the future.”  – Confucius

Dr. George C. Kaiser began his Presidential Address, “Paranoia or Reality?” (Ann Thorac Surg 1998;65:1201-6), by recalling the Society’s initial meeting in St. Louis. Thirty years later, he said that it has been an eventful year for our specialty, and he made a comparison to business in that we have experienced an “inflection point,” from which we could decline or go on to new heights. He went on to discuss the major changes in our specialty.

The first change was in funding. He recounted the Health Care Financing Administration’s evaluation of our work units and said it represented “the beginning of a steep downward spiral of reimbursement.” Dr. Kaiser noted that surgical procedures “have been performed at a consistently lower volume than had been anticipated” and that “funding from government and voluntary agencies and philanthropic groups continues to erode.” He called upon us to work more closely with industry.

Next, he bemoaned the fact that litigation and complex regulatory processes were stifling development, and he called for liability risk to be controlled while public safety is preserved. He then discussed the arguments for and against the promotion of non-specialist care, and he argued for the preservation of specialists. He highlighted the growth of alternative therapy and said that “patients and their families are becoming more sophisticated and knowledgeable. They are eager for education and explanation of their problems.”

A discussion of the STS National Database ensued, and Dr. Kaiser predicted that “in the future, everyone involved in health care delivery increasingly will demand longitudinal outcomes data.” He went on to say “it is essential we supply data and analyses that are valid and appropriate to those who request it.” He recounted the efforts of Bob Replogle, Peter Greene, and Tom Ferguson in getting STS more involved with the Internet. He discussed new technology and quoted Fuchs by saying that “change is the most important force behind the escalation of health care expenditures.”

Dr. Kaiser concluded his address by saying that “these new challenges facing us are as great as any clinical ones we have faced in the past. To confront them requires the development and application of new skills for which we previously have not been formally trained.” Furthermore, he stated that “addressing these issues will require our collective wisdom. We must all become involved.”

In his Presidential Address, “Thoracic Surgery at Century’s End” (Ann Thorac Surg 1999;67:897-902), Dr. Richard P. Anderson looked to “describe how the twin influences of scientific innovation and societal change have interacted to produce thoracic surgery at century’s end.” He enumerated the advances in thoracic surgery in the 20th century, including the creation of the National Institutes of Health, the formation of new medical schools, an increasing number of thoracic surgeons, constraints of Medicare spending, the rise of managed care, payment reform, and how The Society of Thoracic Surgeons “has grown and expanded to meet the challenges of a highly organized and complex health care environment.”

He mentioned the importance of government relations, the STS National Database that was established in 1987, and the rising importance of the Internet. He reminded us that we, as thoracic surgeons, “have been given a priceless gift: the satisfaction that comes from sustaining human life by our own efforts.” He highlighted four elements that we must carry forward into the 21st century.

First, we must have the spirit of innovation. “We no longer have the professional autonomy that allowed our predecessors to try new things independently,” said Dr. Anderson. He urged us to promote innovation by supporting young investigators, to have more collaboration with industry, to communicate broadly through the Internet, and to “emerge from our competitive environment and create a cooperative one.”

Second, we “must remain adaptable to social changes,” learn to adapt to the demands for accountability, and “make our results readily available to our patients and to the public.” Dr. Anderson said that “faulty rankings by parties using faulty data and poor analysis hurt us all.”

Third, we must resist further fragmentation of our specialty. “Despite our size, our voice in public matters that concern our patients has been strong and effective. It can only remain so if we resist fragmentation and remain together,” he said.

Finally, we must focus on our patients. We must “engage in the public dialogue about resource allocation” and “find and support better alternatives to for-profit health care delivery systems.” We must evaluate new treatments to see if they save lives and reduce suffering. “Our obligation is to see that the public thoroughly understands the benefits that we bring,” said Dr. Anderson.

Lastly, he concluded, “there is a world of work and opportunity awaiting us. Let’s go.”

“Cardiothoracic Surgery in the New Millennium: Challenges and Opportunities in a Time of Paradox,” the Presidential Address delivered by Nicholas T. Kouchoukos (Ann Thorac Surg 2000;69:1303-11), set up several paradoxes. A paradox, according to the Random House Dictionary of the English Language, is “a statement or proposition seemingly self-contradictory or absurd, but in reality expressing a possible truth.”

The first of these is education; it is increasingly expensive to be educated in cardiothoracic surgery, and with decreasing reimbursement, the ability to repay the debt incurred is decreasing. Dr. Kouchoukos noted that the average debt at the completion of training is $80,000, and he noted the decline in the number of applicants for training.

The next paradox is that the knowledge base of cardiothoracic surgery has increased, while the length of training has not. He called for a change in the duration of cardiothoracic training to be 3 years at a minimum and noted that the American Board of Thoracic Surgery had voted to eliminate, at some future time yet unspecified, the requirement for board certification in general surgery. Importantly, Dr. Kouchoukos also called for a postresidency educational process to be implemented, for the mentoring of young surgeons, and for all of us to be positive role models.

The next paradox is in technology; improvements will better prevent, diagnose, and treat disease, yet there are shrinking resources in the public sector to fund these improvements. Dr. Kouchoukos stressed that we must continue to support the STS National Database, and he called on us to partner with governmental agencies at all levels. “Above all, we must remain optimistic about the future of medicine and vigorously support medical research,” he said.

He noted the paradox involved in ethics—the physician has a primary responsibility to the patient, but also must submit to the needs of the medical care organization. This creates not only a moral dilemma but introduces a potential conflict of interest. Dr. Kouchoukos said that “we must remain the advocate of the individual patient” and “we must forcefully speak out about our values and remain ever mindful of the dangers of complacency and silence.”

The last paradox is in public policy; we are the wealthiest nation on earth, yet 44 million people currently lack health insurance. He said “it is time for all physicians, including cardiothoracic surgeons, to use our still considerable prestige and influence to pressure our legislators to address and resolve this paradox in the near future rather than 20 or 30 years from now.” He added, “we can have a similar effect on the problem of universal access to health care by working with other advocacy groups to effect change.”

Dr. Kouchoukos finished with a discussion of the specialty’s challenges and opportunities. We are faced with enormous challenges, but we have the opportunity to “improve the quality of the lives of our patients and of our own lives as well.” We should “meet the challenges head on.” We must improve the quality and lower the cost of training, improve the quality of postgraduate education, be positive role models and committed mentors, and have a “higher level of commitment to teaching and to training that has existed in the recent past.” Furthermore, we must critically evaluate new technology, be strong advocates for our patients and maintain the doctor-patient relationship, maintain our professionalism, and battle for affordable health care. Finally, we must “support the important initiatives of our Society with volunteerism and with dollars.”


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