Practice Management: Working with Cardiologists: From Heresy to Dogma

In this edition of STS News, Dr. Raymond Singer describes his personal journey through changes that have affected our entire profession. Many of us may find similarities with our own career experiences.
--Frank L. Fazzalari, MD, MBA, Chair, Workforce on Practice Management


Raymond L. Singer, MD, MMM, CPE, Physician in Chief, Institute for Special Surgery
Lehigh Valley Health Network, Allentown, Penn.

After completing my cardiothoracic surgery training in 1992, I joined a private practice cardiac surgery group in Pennsylvania. As the 90s progressed, the challenges to private practice began to mount.

In November 1992, the Pennsylvania Health Care Cost Containment Council published its first cardiac surgery report card. Although public reporting is now commonplace, it was a shock to surgeons at the time. Collegiality became strained as surgeons recognized the potential benefits and risks of receiving a report card, often published on the front page of the local newspaper.

Another challenge was steep Medicare cuts circa 1996. Young surgeons faced the risk of not becoming a partner in the practice. New grads were often dismissed after 2 years of service or kept on as perennial employees so that senior partners’ compensation would not diminish.

In addition, the elimination of the Certificate of Need in Pennsylvania led to the opening of multiple small heart surgery programs, which typically recruited senior partners to lead these startups. Small hospitals had visions of renewed financial stability and competed to recruit experienced heart surgeons to get their programs off the ground.

In the face of the chaos created by splintering private practice surgical groups, many heart surgeons, including myself, sought job security and referrals by joining private cardiology practices—a move that was considered heresy at the time.

As this played out across the country, tensions rose. Surgeons who did not join such arrangements found their referrals dropping off. This resulted in many complaints at meetings and even lawsuits. I recall being at the 2003 STS Annual Meeting in San Diego where a surgeon stepped to the microphone and suggested that “any cardiac surgeon who joined a cardiology group should not be in The Society of Thoracic Surgeons.”

I remained in the cardiology group for 5 years, leaving in 2004 to become part of the multispecialty hospital-employed practice where I work today. Looking back, my experience in a cardiology group, ironically, would be a preview of what is now considered clinical dogma—that is, the importance of collaboration, forming multispecialty teams, service lines, and sharing hybrid technologies.

To adopt hybrid procedures, such as TAVR, cardiologists and cardiac surgeons literally need to stand side-by-side.

With cardiologists as my partners in the 90s, I had direct access to educate them about the importance of early referral for patients needing mitral repair. We developed team-based clinics that might have taken longer to adopt had we been on competing teams.

Fast forward to 2017. The key buzzword is “collaboration.” As technologies continue to advance, it has become clear that to adopt hybrid procedures, such as TAVR, cardiologists and cardiac surgeons literally need to stand side-by-side.

Today, traditional academic departments are being remodeled into service lines and multidisciplinary clinics. The truth is, cardiac surgeons have more in common with cardiologists than they do with other surgical specialties; however, in the traditional academic model, cardiac surgeons are in the department of surgery, while cardiologists are in the department of medicine. New silos attempt to better align physicians along service lines, often within the same practice or institute.

Some may say that the modern alliance is a shift from financial motivation to improving quality and value for patients. I would suggest that financial stability and growth need to remain a necessary part of any hospital’s value equation. Whether it’s hybrid procedures or clinical pathways, we strive to provide the best value to our patients; in turn, our hospitals are financially rewarded, allowing for further capital investments to improve patient care.

While teaming up with cardiologists was criticized in the past, it is seen as the critical foundation for success today. Perhaps at our next Annual Meeting, a surgeon will rise to the microphone and suggest that “any cardiac surgeon not working with a cardiologist should not be in The Society of Thoracic Surgeons!”