Robert A. Wynbrandt, Executive Director & General Counsel STS News, Spring 2018 -- Most readers of STS News will not independently remember this, but there was a time when physician advertising was banned in the United States. It was not so long ago when the American Medical Association, then boasting a membership that actually included a majority of US licensed physicians, maintained and enforced such a ban. However, in the wake of a 1975 US Supreme Court decision that declared Virginia’s ban on lawyer advertising unconstitutional, the Federal Trade Commission filed a complaint against the AMA for its analogous misdeeds in the medical profession. By 1980, my first year in legal practice, a federal appellate court had rejected the AMA’s challenge and upheld an FDA Order that it “cease and desist from promulgating, implementing and enforcing restraints on advertising ... by physicians ...” except when such advertising was false or deceptive. That ruling was finally upheld by the Supreme Court in 1982. As any casual reader of an airline inflight magazine can attest, the AMA’s former ban on physician advertising is now as antiquated as all those Disney VHS videotapes I bought when my kids were young. And not only is physician advertising alive and well, but information about physicians is abundant and readily available through the internet and all forms of social media.  In this world of plentiful information available to the public about physicians, as a function of both advertising and other promotional vehicles created by physicians, as well as numerous sources of information generated by third parties, cardiothoracic surgeons are wise to pay attention to their public images, e.g., by periodically “googling themselves” and learning about how they are depicted on the internet, which can be a source of false and misleading information. Some fortunate STS members may work at hospitals where this task is performed for them by marketing professionals. Such due diligence might strike some as a waste of time, if not narcissistic, but nothing can put a damper on one’s professional image—and potentially one’s career—like false or misleading information disseminated to the public. And while it’s true that some false or misleading information is virtually impossible to eliminate or correct in the virtual public square, just the knowledge of what your colleagues, administrators, and patients may be hearing and reading about you will at least arm you with information that you can affirmatively counteract in your dealings with them. Cardiothoracic surgeons are wise to pay attention to their public images. Medical specialties and their national societies also have to be mindful of their images. A negative image of a specialty impacts the interests of prospective trainees (i.e., the lifeblood of a profession), how its health policy positions are perceived by legislators and regulators, and most importantly how they are viewed by patients and prospective patients—the ultimate consumers of their services. Lest we forget, it was also not that long ago when the image of cardiothoracic surgery was not so rosy (see declining numbers of residency applications, William Hurt in “The Doctor,” etc.). In furtherance of its image, not to mention its organizational mission for which “the highest quality patient care” is the endgame, the Society recently began to address a number of broad social issues that have significance for the well-being of the specialty. STS action in three such arenas started with important member surveys: on diversity and inclusion, on opioid use in cardiothoracic surgical procedures (see page 2), and on gender bias and sexual harassment. While some of our members might deem such issues as counterintuitive—or even inappropriate—for focus by an organization such as ours, STS is not alone among national medical specialty societies in taking an active interest in these topics; a specialty society that is sensitive to cultural norms and alert to its own culture serves its public image, reflects well on its members, and is emblematic of the STS core value of professionalism. To that end, this column is both a thank you note to those who have participated in these surveys and a plea for the time and attention of all our readers for participation in our future surveys of this nature. You will be hearing much more on all of these fronts. One final comment about image that you’re likely to hear consistently from public relations professionals: the image that one seeks to cultivate must be authentic or it will lack credibility. Thus, astute readers of this space will note that the photographic image accompanying this column no longer reflects the 40-something-year-old me, but rather the 60-something-year-old me, thanks largely to the public shaming to which I was subjected by then-First Vice President Keith Naunheim prior to our 2018 Annual Meeting. This updated headshot is provided to enhance my own credibility (“if he’s misleading us about what he looks like, who knows if he’s otherwise misleading us?”) and as a commercial for a terrific innovation introduced by STS Director of Marketing and Communications Natalie Boden on the exhibition floor in Fort Lauderdale. If you did not take advantage of this free opportunity at our 2018 Annual Meeting, please be assured that we will repeat it next year in San Diego; I encourage you to stop by. In fact, you can consider your free headshot an STS return on your membership investment, to the benefit of your image.
Apr 6, 2018
5 min read
STS News, Spring 2018 -- Your technical skills in the operating room are, of course, essential to developing a thriving cardiothoracic surgical career. But understanding how your procedures should be coded, navigating contract negotiations, and finding a good mentor also are important elements in ensuring your success. To assist cardiothoracic surgeons with all aspects of practice management, the Society offers a wealth of tools on its website, which you can find at sts.org/resources. Offerings in this section of the website include: Coding and Reimbursement Resources Submit specific coding questions to the Coding Help Desk. This tool is designed to assist STS members and their staffs with coding, billing, and reimbursement challenges. Risk Calculators Risk calculators provided by the Society can be valuable resources for patient consultations. The STS Short-Term Risk Calculator allows you to calculate a patient’s risk of mortality and morbidities following coronary artery bypass grafting (CABG) surgery, aortic valve replacement, mitral valve replacement, and more, based upon data from the STS National Database; the ASCERT Long-Term Survival Probability Calculator, based upon data from the STS Adult Cardiac Surgery Database and the Centers for Medicare & Medicaid Services, allows you to calculate survival probability following isolated CABG in patients aged 65 years and older. Clinical Practice Guidelines and Expert Consensus Statements Take advantage of these clinical decision-making aids. Sixteen cardiothoracic surgical topics are covered in the Society’s clinical practice guidelines, which are based on an exhaustive review of scientific evidence published in the medical literature. STS Expert Consensus Statements represent the collective opinions of expert panels on clinical topics; the most recent statement focuses on resuscitation of patients who arrest after cardiac surgery. Practice Management Columns Access an archive of Practice Management columns from past issues of STS News and read about topics such as the importance of collaborating with cardiologists, how to navigate an employment model environment, and bundled payments for CABG. Career Resources Get career advice, especially if you are in your first 7 years of practice: An extensive document provides answers to frequently asked questions on topics such as clinical interactions, program development, personal finances, contracting, and research. A new blog offers practical tips on all aspects of early career development. Topics include how to obtain research funding as a new investigator, balancing clinical, academic, and administrative responsibilities, and communicating with referring physicians; new posts are planned monthly. Find out how to connect with your fellow cardiothoracic surgeons on social media. You can access a feed of the @CTSurgCareers Twitter account, as well as learn about upcoming TweetChats. A just-released video roundtable features STS members Vinay Badhwar, MD, Shanda H. Blackmon, MD, MPH, Melanie A. Edwards, MD, and David D. Odell, MD, MMSc discussing the importance of mentorship, what the Society is doing to promote mentorship for early career surgeons, and defining the relationship between mentor and mentee. If you have suggestions on additional practice management resources that you’d like to see from STS, contact the Education Department.
Apr 6, 2018
3 min read
Mentorship is an important component to success for many up-and-coming cardiothoracic surgeons.
18 min.
Keith S. Naunheim, MD, President STS News, Spring 2018 -- There are many longstanding issues afflicting our cardiothoracic surgical specialty, including threats to reimbursement, liability issues, and burdensome regulation. The profession has addressed and continues to address these issues; however, just recently, a chronic but previously unrecognized danger to the specialty and our patients was identified—the national epidemic of opioid abuse. The opioid epidemic is a real phenomenon with devastating consequences in the US. The number of overall deaths from overdoses has more than doubled in the last decade, peaking at about 64,000 fatalities in 2016 and exceeding the deaths from traffic accidents or gun violence. Fully, two-thirds of those deaths were related to opioid overdose. The etiology of this problem is multifactorial and involves many health care players. Pharmaceutical companies intentionally downplayed the addiction risk of new pain medications while engaging in morally indefensible sales and distribution practices. In the 1990s, the American Pain Society, funded by the same pharmaceutical companies, touted pain as “the fifth vital sign,” insisting on visual pain scales with aggressive management that included narcotics. The Joint Commission published a pain management guideline in 2001 encouraging this pain management strategy, and in fact published a continuing education booklet (again funded by drug companies) citing studies suggesting “there is no evidence that addiction is a significant issue when persons are given opioids for pain control.” The Federation of State Medical Boards called for the punishment of doctors who inadequately treated patients’ pain, while simultaneously accepting pharmaceutical company money to produce drug prescribing guidelines. Hospitals implemented patient satisfaction scores specifically addressing inadequate pain management issues and threatened to downgrade physicians’ performance assessment for poor scores. Even the US legal system was involved, with physicians found financially liable for inadequate pain management practices (Bergman v. Chin). Despite these facts, it is the physician community that has been vilified by the media for wanton and irresponsible prescribing practices. While it is true that there are unscrupulous doctors at “pill mills” who are guilty of unethical practices, it is also true that a portion of the blame could be assigned to responsible and caring physicians misled by the above-mentioned authorities and institutions. This group includes cardiothoracic surgeons who, for decades, have utilized thoracotomy incisions to achieve intrathoracic access. This approach produces a combination of muscular, skeletal, mesothelial, and neuropathic pain, which arguably makes thoracotomy the most painful incision one can undertake, both with regard to the immediate postoperative period and in the long term. A paper presented in January at the STS Annual Meeting reported that 14% of patients undergoing thoracoscopy or open thoracotomy were still filling opiate prescriptions 6 months after surgery. As surgeons, we need to be conscious of such results and take action directly addressing the issue of post-thoracotomy narcotic usage. As surgeons, we need to … take action directly addressing the issue of postthoracotomy narcotic usage. STS recognizes its role and that of its members in confronting this ongoing epidemic. Our first action is to better understand the current state of practice and, therefore, the Society has undertaken an electronic member survey requesting specific information regarding the routine practice of opioid administration and prescription following cardiothoracic surgery. Information regarding standard dosage, number of pills, and duration of treatment has been requested both from surgeons and associated providers who have been asked to participate (physician assistants, advanced practice nurses, anesthesiologists). This information will help form the foundation for the Society’s response to this nationwide problem. It is hoped that the results of this survey will help STS identify best practices and then issue expert clinical opinion regarding optimal perioperative utilization of both opioid medication and nonnarcotic pain control methods and medications.  In addition, the Society will undertake ongoing education initiatives to help guide the membership in future practice. This will include emphasis of ERATS (Enhanced Recovery After Thoracic Surgery) protocols, a topic that was highlighted at the recent Fort Lauderdale meeting (see page 8 for information on how to access a related video roundtable and podcast). ERATS also will be addressed specifically at the upcoming STS Critical Care Conference in October, and it is expected that next year’s Annual Meeting in San Diego will highlight the issue of perioperative pain management and responsible perioperative opioid utilization in breakout sessions. It is unrealistic to expect that cardiothoracic surgeons will be able to forgo narcotic medication completely given the nature of our operative incisions. However, both you the members and our patients can and should expect the Society to help guide practitioners in the measured and judicious approach to opioid usage in both inpatient and outpatient arenas. Such an approach will help minimize the risk of addiction for our patients and help address the ongoing epidemic. It seems that this scourge caught most of America flat-footed in 2017, and our specialty was no exception. But now I believe we all recognize that the problem exists and it is one in which cardiothoracic surgeons have unwittingly played a role, however unintended. Yes, we have a problem, but now we pledge that—together—we will become part of the solution.
Apr 6, 2018
4 min read
STS News, Spring 2018 -- After a chaotic few weeks immediately following the STS Annual Meeting, the Society opened its doors to a newly constructed headquarters office on February 20. The street address is the same (the American College of Surgeons building in Chicago at 633 N. Saint Clair St.), but the difference between the old space on the 23rd floor and the new space on the 21st floor is significant. “We worked with some terrific architects and a team that included an experienced project manager, contractors, and building management to create a workplace that is both attractive and, what is most important to our members, conducive to employee satisfaction and productivity,” reported STS Executive Director & General Counsel Rob Wynbrandt. “The design utilizes every square inch effectively, such that we have increased the number of ‘seats’ by 19 and still enlarged key common areas like our new Boardroom and café. Special recognition is due to Director of Finance and Administration Keith Bura and Administrative Manager & Executive Assistant Cheryl Wilson for their contributions to this long-term project.” Visitors are greeted by a large, backlit STS logo and a pedestal that features the President’s Gavel. The process actually started in 2015 when STS surgeon leaders and senior staff looked ahead to an April 2018 lease end date and began considering how to accommodate the Society’s continued expansion; the number of STS employees had grown significantly—from 9.5 full-time employees in 2002 to what is now a budgeted 76 in 2018. After working with real estate brokers to review a few other locations in downtown Chicago, the decision was made to stay at the ACS building. STS then retained an architectural firm to design a space that not only would fit the growing staff over the course of a new 11-year lease term, but also have a modern and sophisticated appeal. The final design includes a gray, white, and blue color scheme, accented with wood tones and glass that allows in a lot of natural light. In the weeks leading up to the move, after initiating a document digitization process that still continues, staff packed up dozens of orange moving crates, recycled hundreds of pounds of paper, shredded hard copies of sensitive documents, and sent boxes of files to offsite storage in an effort to reduce clutter in the new space. The café features a wall of windows and ample space for employees to enjoy their breaks and lunches. The entire move was completed in just one long weekend.  “I can’t deny it; for some of us on the staff who are admitted dinosaurs—wedded to paper—the lead-up to our move was time-consuming and stressful,” said Wynbrandt. “Now that we’re through the hardest part, though, it was all worth it. And we even benefitted from the secondary gain of team-building that comes with any difficult shared experience.” An important goal for the new design was to make the Society’s branding more prominent. Upon entering the reception area, visitors are greeted by a large, backlit STS logo and a pedestal that features the President’s Gavel made from a cherry tree on the Michigan estate of John Alexander, MD, recognized by many as the founder of American thoracic surgery. Photos of all STS Presidents, past and present, will be featured on nearby walls. The Boardroom is now large enough to host surgeon leaders for important meetings. Just beyond the reception desk is a large Boardroom with exterior windows (something the previous headquarters office lacked), which will host STS surgeon leaders for important meetings such as the Annual Meeting program planning meeting in September. A new and improved Founders Room still pays homage to the past by memorializing the surgeons involved in the formative activities of the Society, while a redesigned Library houses a complete collection of The Annals of Thoracic Surgery and other important STS documents; all of the conference rooms, including three new “huddle rooms,” have advanced IT capabilities. The entire Chicago staff looks forward to greeting members and showing off the new headquarters space. The next time you are in Chicago, staff would be happy to give you a tour! Take a video tour of the new space at sts.org/HQvideo, and see more photos at sts.org/HQphotos.
Apr 6, 2018
4 min read
Should patients remain active before, during, and after cardiac surgery? Some surgeons have opposing views.
15 min.

The STS National Database recently expanded to include a registry for clinical outcomes of patients who receive a mechanical circulatory support device to treat advanced heart failure. The STS Intermacs Database adds important longitudinal data to an already comprehensive, highly respected clinical outcomes database. David Shahian, Frank Pagani, and Robert Kormos discuss how Intermacs will complement the STS National Database and how the data can be used for research and performance improvement.

19 min.
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Career Development Blog
Finding the ability to balance one’s professional, academic, and clinical responsibilities is essential—and the sooner this is achieved, the better.
4 min read
Damien J. LaPar, MD, MSc
New technologies and innovative treatments are making it easier to successfully diagnose and treat patients with lung cancer.
17 min.
Four leading experts discuss how catheter-based techniques will re-emulate the gold standard for mitral valve surgery, the important role of 3D Echo technology, the need for transseptal puncture skills, and navigating the local politics.
18 min.
Numerous studies predict growing shortages in the physician workforce in the United States, especially among cardiothoracic surgeons.
19 min.
Review of the practice guideline on the use of blood thinning medication (anticoagulants) during heart surgery.
9 min.