Section of Cardiothoracic Surgery, University of Cincinnati, Cincinnati, OH.
Address correspondence and reprint requests to John R. Mehall, MD, Section of Cardiothoracic Surgery, University of Cincinnati, 231 Albert B. Sabin Way, PO Box 670558, Cincinnati, OH 45367; E-mail: firstname.lastname@example.org.
It is not the strongest who survive, nor the most intelligent, but those most responsive to change.
The future of cardiovascular and thoracic surgery is bright for those willing to innovate and evolve.
Cardiothoracic surgical specialists provide therapy for the most common life-threatening diseases of an expanding and aging patient population. We have highly evolved therapies with an unparalleled record of safety and excellent long-term effectiveness. Yet, at a time when our practices should be busy and vibrant, we are experiencing a shrinking scope of practice and dwindling reimbursement, we cannot readily entice new trainees into the field, and cannot find enough jobs for those who do complete the training. Although the reasons for these problems are complex and multifactorial, it is important to recognize one central and bittersweet reality. For all its efficacy and safety, the primary therapy that we have historically offered our patients—major operations—is markedly unappealing and undesirable to them. Patients submit to major operations only when they think that they have no other option—a fact that is easily lost on those of us who perform these procedures everyday. This reality is not new and has not changed, but patients' aversion to operation was historically not a factor. Previously, patients with thoracic and cardiovascular disease had little choice when medical therapy was ineffective and no choice other than major operative therapy existed. With no reasonable alternatives to choose from, cardiothoracic surgeons did not have to provide therapy that appealed to patients, only therapy that was effective.
Due to rapid advances in technology, however, the number of alternatives to operation continue to increase. Now, many patients have options other than operation. The ability of incisionless interventionalists and natural-orifice proceduralists (nonsurgeons) to provide therapy has been greatly enhanced. Because these new therapies are novel, incisionless, and technology driven, they appeal to patients and have been heartily embraced by industry. The growing burden of cardiovascular and thoracic disease in our population with its corresponding market value has resulted in unparalleled efforts to develop and promote therapeutic options that avoid operations. The forces driving this revolution in cardiovascular therapy are increasing technological capability, industry dollars, and patient demands. The examples in our field are seemingly endless: drug-eluting stents for coronary disease, catheter-based valvular procedures, percutaneously implanted ventricular assist devices, catheter ablation for atrial fibrillation, endovascular treatment of aortic and peripheral vascular disease, radiofrequency ablation of lung and esophageal cancer, photodynamic therapy for Barrett's dysplasia, endobronchial treatment of emphysema, and many others.
The existence of alternative therapies with glitzy appeal advertised in a way that would have been considered unethical not long ago has made it increasing difficult to have patients referred to surgeons, and fewer still are willing to undergo operation. Patients increasingly value quality of life, recovery time, and other factors and weigh these factors against the effectiveness of the procedure. Although cardiothoracic operations have a proven record of safety and long-term effectiveness, and many new therapies have little or no track record, this factor is poorly valued, even by “informed” patients. Unless these new therapies are shown to be completely ineffective or dangerous, they will continue to replace traditional operations because patients prefer them, and they are prescribed and performed by the physicians who see the patients first.
This reality has started a paradigm shift and innovation revolution in cardiothoracic surgery. The ongoing revolution in therapies for cardiovascular and thoracic diseases is what brought almost 60 cardiothoracic surgery residents from across the nation together with pioneering practitioners over a 3-day weekend for the Cardiothoracic Technology Symposium (www.ctsymposium.org). The CT Symposium was developed by the Thoracic Surgery Residents Association and the Thoracic Surgery Directors Association, and sponsored by the International Society for Minimally Invasive Cardiothoracic Surgery and industry. The CT symposium, hosted by the Center for Surgical Innovation at the University of Cincinnati, highlighted emerging technologies and minimally invasive therapies in cardiothoracic surgery. The course included didactic lectures and animal and cadaver wet-laboratory stations for hands-on mentored learning.
The symposium was intended to expand the horizons of cardiothoracic residents beyond traditional incision-based cardiothoracic surgery, help prepare them for a rapidly changing surgical marketplace that increasingly demands expertise in these areas, and to interest them in pursuing and eventually developing new areas of cardiothoracic surgical innovation and practice. As the course progressed, it became increasingly clear that cardiothoracic surgery has reached and is rapidly passing a watershed moment in the history of our specialty.
Consider these observations: Despite its importance to our field, both presently and historically, it wasn't until the last hours of the symposium that coronary artery disease was discussed.
1. No procedure taught during the course required a sternotomy or thoracotomy;
2. Every station in the hands-on labs required video imaging, rather than peering into the wound.
These observations highlight the remarkable transformation that is occurring in our specialty, and how different our future will be in comparison to the traditional open operations that are our heritage. No longer is it necessary to see the whole heart or lung, but rather only the part being operated upon, and frequently even that only on a monitor. For many procedures, the essence and the basic surgical principles involved are preserved, but the methods and technologies we now use are excitingly different. Contrarily, for other approaches, such as catheter-based technologies, the essence of the operation and the principles involved are entirely different. The importance of new imaging technologies in facilitating this revolution cannot be overstated. Although advances in videoscopic and other direct visualization modalities enable us today, future procedures will involve indirect imaging modalities such as stereoscopic 3-dimensional ultrasound and others.
The success of the CT symposium and the growth of ISMICS reveal the true future of our specialty. We can ensure our future by transforming our operations into procedures that patients feel comfortable choosing. Only when patients and referring physicians stop seeing operations as a therapy for last resort will long-term effectiveness and other arguments resonate. The rapid growth of ISMCIS shows that an increasing number of cardiothoracic surgeons are choosing to actively engage in this revolution, learning and developing new technologies that will transform cardiovascular and thoracic therapy. By doing so, they will contribute to and build upon our unique surgical expertise concerning cardiothoracic disease processes, use our full knowledge of the best current therapies available for each patient, and continue our proven record of professional leadership that assures new therapies are developed with appropriate attention to outcome measures and results.
Surgeons are better positioned to lead this transformation than anyone else. It should be easier for surgeons to transform our current operations—with their well-established efficacy—into less invasive procedures, than for nonsurgeons trying to develop new procedures from scratch. We must simultaneously reintegrate ourselves into patient care and therapeutic decision making. Cardiothoracic surgeons can no longer be one-dimensional practitioners waiting passively at the end of the therapy line for patients to be referred. The increased therapeutic ability of physicians who previously referred to and relied on cardiothoracic surgeons for therapy has highlighted our highly dependent position. We must work collaboratively with our colleagues, as is already being done in endovascular surgery, arrhythmia surgery, thoracic oncology, and other areas if we are to be involved in therapeutic decision making and be effective advocates for our patients.
Despite rosy predictions of massive cardiothoracic surgeon retirement and an aging patient population with a growing disease burden, this accelerating replacement of traditional operations with less invasive therapeutic alternatives provided by nonsurgeons is the undefined variable that could negate the future predicted cardiothoracic surgeon deficit. Failure to become involved in innovation and continued evolution of our established operations will accelerate the marginalization of our field. To stop our shrinking scope of practice and reestablish ourselves as the leading providers of cardiovascular and thoracic care we must inform patients about the excellent effectiveness of our therapy, become reintegrated into patient decision making, and most importantly offer patients therapy that they are comfortable choosing.