Menkis, Alan H. MD
ISMICS (International Society for Minimally Invasive Cardiothoracic Surgery) is an exciting society. Less invasive cardiac surgery was the motivation to start this society. OPCAB (Off-Pump Coronary Artery Bypass), minimally invasive valve, and coronary bypass surgery were being developed by growing numbers of innovative surgeons who wanted to come together to share ideas and experiences. This happened in the mid-1990s, and many of the pioneers came from the pioneering surgery of the 1980s, that is, heart and lung transplantation.
There was a need to address newer ways of doing cardiac surgery primarily to respond to two developments. The first was the challenge presented by percutaneous intervention; the second was the body of literature suggesting that cardiopulmonary bypass was the cause of significant neurological injury leading to cognitive dysfunction. Innovation led this response, and, as a result, there have been great advances, often introduced at this meeting, in techniques and technology in cardiothoracic surgery. You can see, in abundance, examples of this innovation in the scientific content of this meeting and on display in the exhibit hall.
Prague is a wonderful city, which I hope you will be able to experience during this meeting. Prague also represents an interesting segue to robotic surgery. The term robot comes from Czech and Polish, and it has its origins during feudal times when serfs would be forced to work 2 or 3 days per week in their master’s fields. A Czech playwright, Karel Capek, wrote a play in 1919 called Rossum’s Universal Robots. Robotic workers were created to do the mundane work required, which allowed humans to engage in more creative endeavors. However, the machines eventually organized, ran amuck, and tried to destroy civilization. The images from the playbill are an example of how art foreshadowed the totalitarian horrors of the last century in Europe.
Marshall McLuhan, a Canadian communications philosopher, said we live in a “Global Village” “where the globe has been contracted into a village by electric technology and the instantaneous movement of the information from every quarter to every point at the same time.”1 We can see that in this society. There are excellent cardiac surgeons and cardiac centers around the world. We communicate not only at the annual meeting but the annual meeting would not occur if we could not reach our colleagues around the world almost instantaneously. It is through meetings like this that ideas can be shared.
Cardiovascular and thoracic care has made great strides since the formation of this society. We have been on the vanguard of technological innovation in our field. To match this innovation, we must also innovate to promote excellence and sustainability. As experts in cardiac care, we must have a greater role not only in influencing and participating in the care of cardiac patients but also in developing the related policies and priorities. The danger of failing to do this is to leave these decisions to others, risking that the best interests of our patients and our profession may not be met.
Hence, there are three themes I believe to be critically important at this juncture in the care of patients who require cardiovascular and thoracic surgery: policy, politics, and performance.
The Global Burden of Disease Study 2010 represents the second iteration of a multinational study.2 It involved almost 500 scientists, 300 institutions, and 50 countries. Initially, the World Bank, followed by the Bill and Melinda Gates Foundation, funded it. In 1990, they described 107 diseases and injuries and 10 risk factors, and in 2010, these more than doubled to 235 causes of death and 67 risk factors. They assessed mortality, causes of death, years of life loss, disability-adjusted life years, and healthy life expectancy, and they did it with statistical rigor required by a large administrative database.
The World Health Organization currently views obesity as a pandemic. Worldwide obesity has nearly doubled since 1980. In 2008, a total of 1.4 billion adults older than 20 years had a body mass index of greater than 25; 200 million men and 300 million women had a body mass index of greater than 30, which means that half a billion people are obese. Sixty-five percent of the world’s population lives in countries in which overweight and obesity kill more people than underweight does.3 Thus, for the first time in the history of man, too many calories or obesity and its complications will kill more people than too few calories or starvation and malnutrition.
Cardiovascular disease has surpassed communicable diseases as the leading cause of death, now causing more than 30% of global mortality. This is not limited to the western world. The statistics on obesity rates on selected countries show the United States to be the most obese country (34% of the population); however, Mexico, New Zealand, Australia, Britain, Canada, Chile, and South Africa are not far behind.4
Not only is the incidence of obesity dramatically rising, it is, in particular, affecting our children. At present, Greece, USA, Italy, and Mexico have the fattest children in the world.5 Obesity and its problems cause the United States 300 billion in extra medical expenses and lost productivity. The societal cost of obesity is greater than the societal cost of tobacco. In Salt Sugar Fat, investigative reporter Michael Moss draws a parallel between the food industry of today and the tobacco industry before our awakening to the dangers of tobacco.6 His book exposes the food industry much like Barbarians at the Gate exposed the tobacco industry a number of years ago.
In China, for the first time, people who weigh too much outnumber those who weigh too little. In France, obesity has risen from 8.5% in 1997 to 14.5% in 2010. Nestle, the food giant, does a flourishing business in Paris. Nestle also owns Jenny Craig, a weight loss company, and it is selling these products in addition to selling products that make you gain weight.
In Mexico, in the past 30 years, obesity rate has tripled, with the fattest children in the world as I mentioned, and the United States is the most obese country in the world. This obesity leads to type 2 diabetes, which has risen to epidemic proportions around the world. This is evident in the developing world more so than in the developed countries.
In the late 1940s and early 1950s, Howard Moskowitz was about to embark on a PhD at Harvard. He chose one in experimental psychology dealing with the psychology of taste and addiction. He was expert in complex mathematical modeling before he did this, and he used that expertise to design and analyze thousands of experiments, involving tens of thousands of subjects and hundreds of thousands of data points. He used this information to discover how to make food attractive and indeed irresistible. He mapped out ingredients and the sensory perceptions these ingredients create. These experiments are also carried out not only for taste but also for appearance, sound, packaging, and marketing variables. Hence, companies can dial in a new product by taking all these data and applying the selected variables to this new product. This is the engineering approach to elicit the greatest craving.
He wrote Selling Blue Elephants: How to Make Products That People Want BEFORE They Even Know They Want Them.7 These products are too irresistible to avoid. The public does not have a chance, and the most vulnerable of us, our children, do not have a chance either. New terms such as mouth feel, how the food feels in your mouth, have been created. We like that crunchy feel and sound; hence, we are all addicted to crisps in Britain and potato chips in the West. They are both salty and crunchy. The industry calls the sugar high or the salt high the “bliss point.” The degree to which we are attracted to these tastes follows an inverted U curve. After the studies are analyzed, the appropriate concentration of salt, sugar, and fat can determine the optimal allure of the ingredients and are balanced against the cost of the ingredients to find the most cost-effective “dose.”
David Kessler, a former US Food and Drug Administration director, wrote The End of Overeating.8 He described five factors in the “hedonics of food.” These are the factors that make food attractive or irresistible, that is, anticipation, visual appeal, aroma, taste and flavor, and mouth feel. The food industry has engaged in highly sophisticated academic research into the brain’s pleasure centers. This is where “sugar and fat sing their siren songs”; exacting addition of precise amounts of these three products to dial in the irresistible nature of foods that get promoted to the public. Kessler coined a term called conditioned hyper-eating to describe the near Pavlovian response that causes us to overeat.
It takes 4 to 5 months for a baby to develop a taste for salt. Hence, our craving for salt is learned.
We learned in medical school that sugar receptors reside at the tip of the tongue. We now know that to be incorrect. There are sugar receptors all the way down our gastrointestinal tract. We are born with the T1R3 sugar receptors from the tip of our tongue to our duodenum. The biology of our children is being exploited to crave sweet calories.
Magnetic resonance imaging studies of the brain after a sugar load is ingested show that the areas that light up are similar to the response to cocaine. In addition, people who have a tendency to obesity light up in a different way than those who do not have a tendency to obesity. There is an intrinsic link between this and the tobacco industry. Warren Buffet is credited for saying, “I’ll tell you why I like cigarette business. It costs a penny to make, you sell it for a dollar and it’s addictive.” Phillip Morris, the largest tobacco company, became the largest food manufacturer in North America when it bought General Foods and then Kraft.
The industry has done its research and discovered how to make eating and overeating irresistible, and the next generation is being targeted. Things that are bad for us are being made attractive to children. Candy cigarettes are being sold to children, and in some societies, there are children as young as 3 years old who are tobacco smokers.
The food and drink industry manufactures 3900 calories per person per day,9 and they have to sell those calories. The worldwide budget for advertising for the food and drink industry is in excess of $40 billion; $4.2 billion was spent for fast-food advertising in the United States alone. The government agency that deals with promoting healthy eating, the Center for Nutrition, Policy and Promotion of Health, invests $6.2 million annually to encourage better eating. This is one thousandth of the investment that the industry uses to induce us to consume more of their products.
In summary, there has been a concerted, successful effort to research the characteristics of food and our attraction to it by the food industry. Their massive investment dwarfs any effort hitherto to educate or influence society’s food consumption habits or the health consequences of overeating and obesity.
In June 12, 2012, The New York Times article How Far Should Governments Go—When Governments Can Help, It Must, Prof R. Bayer advocates that governments should do what they are able or mandated to do.10 How far should governments go in changing social norms, and what policies should it use in creating a healthier community? He advocates that there should be a debate, but it ought to occur with the full appreciation of the price we pay for inaction or timidity.
Tobacco and smoking policies at many hospitals are inadequate. One has to run a gauntlet of smokers to get into too many hospitals. We can eliminate harmful additives and byproducts of the agri-food industry, trans fats, sodium, and excessive calories. Healthy food should be sold in schools and hospitals. This is a growing tendency, particularly in the United States and Britain.
The upshot of all these factors confirms that the epidemic rise in obesity, type 2 diabetes, and coronary disease will be a leading cause of morbidity, mortality, and suffering worldwide for many years to come. We have to position ourselves to be able to contribute to the management of these problems.
How do we address what is very often a matrix structure to our professional environment? We work in systems that include governments, insurance companies, universities, individual departments, and hospitals.
When we get together with our colleagues, conversation often moves to the politics of what we do and of our jobs. I read a book years ago by R.D. Laing called, The Politics of Experience.11 It described the political structure within families. We have a political nature. Take that nature away from a trusting family environment and put it more in the work environment, and behavior may change. We have to deal with administrators, providers, policy makers, leaders, and educators. The question for us is what role do we play in all of this?
We have to deliver a complex multidisciplinary program, whether it is heart surgery, lung surgery, or esophageal surgery. We cannot accomplish that in isolation. We need to deliver excellent quality of care while coordinating teaching in a new model of interdisciplinary education. The lone wolf surgeon just does not exist any longer. Interdisciplinary research is also a focus for many national research agencies; hence, we have to learn how to effectively manage and administer this team. We need a greater strengthening and accountability of cardiothoracic programs. This is bidirectional. We have to be accountable to the patient and to our provider organization. Equally, these organizations have to be accountable for providing the resources to provide the care needed.
Where is this conversation taking place? Politics is a special interest of various individual and institutional stakeholders. It must not subordinate cardiothoracic patient care, research, teaching, or administrative priorities to competing interests within the organization. Rather, these objectives can be achieved only by developing a clear, strong voice on behalf of cardiothoracic patients and the people who provide care for them. Ultimately, we are advocating for our patients. One must align a common vision for teaching, research, and administration as well.
In many jurisdictions, there is a dichotomy between clinical and academic practices, which, in our case, usually means hospitals and universities. In the end, one is often confronted in these matrices by divided loyalties and conflicting priorities. We deal with internists, anesthetists, surgeons, critical care, nursing, and allied health—how do we get everyone on the same page? It has been said that a visionary enterprise is 1% vision and 99% alignment.
In the expression “town versus gown,” the community versus the academic is outmoded. I believe that one cannot be a good clinical surgeon without being a good academic surgeon, which, at the minimum, requires that we know our surgical outcomes. This is not confined to universities. This must be in place in nonuniversity settings as well.
Surgeons can no longer remain silent about their work, leaving advocacy to a small group of medical politicians. More physicians, irrespective of their specialty, responsibility, or seniority, need to enter the public arena: that means in our hospitals, universities, and our communities.
We need to develop more competencies in leadership and management in the health care sector. There will be no shortage of work in our field for many years to come. The factors that contribute to chronic diseases equally affect cardiovascular and thoracic surgery and cancer. I believe that we have a great deal to offer and a greater responsibility to get engaged in the leadership and policies directing cardiothoracic care.
I would like to address the issue of performance in cardiothoracic surgery. We work in multidisciplinary, multispecialty teams every day to deliver optimal cardiothoracic patient care. This is the product that we deliver. How do we assess our ability to deliver this product? We must know our performance or outcomes.
The collection of data, their interpretation, evaluation, and actions based on the data are an integral part of what we do. Do we perform well or poorly? Once we collect these data, we have to subject our work to the critical review of our peers, for instance, publishing it in our journal Innovations. This is fundamental not only to academic research but also to clinical performance and quality control.
The rate of adoption of new technologies in health care lags behind most other sectors.
There was a great series of books by Malcolm Gladwell a few years ago, one of which was called The Tipping Point.12 He said, “We have constructed a world in which the potential for hi-tech catastrophe is embedded in the fabric of day-to-day life.” He maintains, “error is the inevitable result of the natural limitations of human performance and the function of complex systems.” Newer technology does not eliminate errors, and we will have to continually manage errors.
The origins of safety and human performance in aviation began in 1934, when Boeing built the B-17 flying fortress bomber. It was a novel design at the time. It had four engines, electric trim tabs, retractable landing gear, and variable pitch propellers. The test pilot died in a crash on the inaugural flight. The accident investigation determined that the B-17 was more complex than previous aircraft, requiring pilots to manage multiple new technologies for the first time. In this case, the pilot neglected to release the locking mechanism on certain flight controls, so he could not steer or control the aircraft. The accident was deemed by the media to be too much plane for one man to fly. However, the pilots got together, and they created a step-by-step checklist for takeoff, flight, landing, and taxiing. The plane was too complicated to be left to the memory of any pilot, regardless of how experienced or expert. This is what we are now discovering in medicine many years later. Atul Gawande, in 2007, wrote in The New Yorker that medicine has entered the B-17 phase.13 Substantial parts of what hospitals do are now too complex for multidisciplinary teams to carry out reliably from memory alone. Cardiothoracic surgery and intensive care unit life support have become too complex for one person to fly.
The Institute for Healthcare Improvement published that approximately 96,000 deaths in hospitals in the United States were avoidable (2003). They initiated a program called “100,000 lives” to try to reduce the number of those deaths. There is a vast literature on error management. Error is ubiquitous; we all make mistakes and we have to understand that everybody has the capacity for error. Error is not confined to a small subset of bad physicians and nurses. It has a normal Gaussian distribution. Punishment or litigation has been remarkably ineffective in reducing the rate of medical error, even in very litigious societies.
I had the good fortune of taking courses in “Human Performance in Military Aviation” at 17 Wing of the Royal Canadian Air Force in Winnipeg, Canada. We were instructed in the process of error management. What one discovers is that highly functioning organizations continue to experience errors. However, highly functioning groups manage errors better than lower-functioning groups do. Much like the analogy of an iceberg, most of the substance related to incidents and errors lies beneath the surface and is not obvious. There are near misses and processes that could have been addressed to avoid or mitigate errors or accidents. Atul Gawande also stated that, “it’s not how to prevent bad doctors from harming or even killing their patients; it’s how to prevent good doctors from doing so.”
Two thousand years ago, Aristotle believed that, “We are what we repeatedly do. Excellence then is not an act, but a habit.”
We have to embed this attention to error management in our institutions on a day-to-day basis.
William Edwards Deming wrote about the creation of quality and efficiency in industry in the late 1940s and early 1950s. Japan adopted his ideas and philosophy as they rebuilt their industry after World War II; in stark contrast, he was all but ignored in North America. This contributed to Japan becoming an industrial powerhouse during the next 50 years. His basic training was in statistics. He gathered data, interpreted it, and then applied this knowledge to address problems and initiate improvement.
How do we embark on this journey, and what can we learn from industries that have adopted these theories?
Well, this is going to make some stomachs turn; however, we hear terms such as customers, clients, Kaizen Blitz, gemba, lean, product lines, and culture. Medicine has a difficult time with jargon that is not its own. The problem is that the language of the science behind safety and efficiency in the military and industry has not been part of the medical lexicography.
Error management is a science; nevertheless, when an error occurs, the first instinct is to blame someone. However, most errors occur after a convergence of a number of factors. Blaming an individual does not change these factors, and the same errors are likely to recur if this is our response. The one who brought the study of safety into medicine was Robert Helmreich (1937-2012), a psychologist at University of Texas. He espoused the theory that there is a similar culture in aviation as there is in surgery. He said that operating rooms (ORs) are not cockpits but they are similar in many ways. Hence, medicine can learn from aviation. Failures of compliance, communication, procedures, proficiency, and decision making contributed to errors. Operating room surveys confirm that pilots and physicians have common interpersonal problem areas and similar professional cultures. The acceptance of the inevitability of error and importance of reliable data on error management will allow systematic efforts to reduce the frequency and the severity of adverse events.
Airlines and other industries have adopted a system whereby other team members can stop the progress of the assembly line or procedure if they see something that could be harmful. Because of the hierarchical nature of operating theaters, a perfusionist, assistant, or nurse may not want to say anything to the surgeon. However, until anyone on the team can be heard and respected, a truly safe organization or environment cannot be achieved.
There are some impediments to safety and quality initiatives. The attitude of personal invulnerability is a common yet negative component of the professional culture of pilots and physicians. As stated above, the difference between highly functioning teams and low-functioning teams is not whether errors occur but how they respond to the inevitable errors. The following two examples illustrate how we can learn from highly functioning teams in other industries.
How do you change 4 tires in 2.3 seconds? In 2012 at the Hockenheim, Formula 1 German Grand Prix, Jensen Button’s pit crew set a record for the fastest four-tire change pit stop. This did not happen overnight and was recognized by some of our colleagues as a highly functioning team. In 2003, surgeons and anesthetists at Great Ormond Street Hospital for Children identified a number of incidents that occurred in the transition of pediatric cardiac surgical patients from the OR to the pediatric cardiac intensive care unit. They invited a Formula 1 pit crew to observe their hand off of patients from the operating room to the intensive care unit. Process engineers often manage these pit crews. In their comments on the transitions of these patients, they identified deficiencies. There was no apparent chain of command, specific tasks and job descriptions were lacking, there were no checklists, and communications were unclear and incomplete. A number of recommendations were developed and implemented. A sequence of tasks and communications was assigned to specific individuals. Checklists were used. Extraneous conversations and people not involved in the handover were excluded. The results showed that technical errors were reduced by half, errors of omission were reduced by two thirds, and handover time was reduced as well. The lesson learned was that standardization of the handover had to be developed. Checklists must be used.14 Patient handover from surgery to intensive care used Formula 1 pit stop and aviation models to improve safety and quality.
The OR team is composed of a multidisciplinary team of up to 6 to 12 members. This team sometimes changes during the course of the operation. The surgery may have been the extremes of very routine to very stressful. These situations may make members of the team prone to gaps in the information that is given to the receiving team.
The result in the case of the cardiac team at Great Ormond Street Hospital for Children was to change the protocol for the handover from the OR to intensive care.15
Expertise and examples from other industries can be extrapolated to improve patient safety in particular areas of medicine involving handover in patients or information. In our Cardiac Sciences Program in Winnipeg, we have adopted these principles in the transitions of patients from the OR to intensive care. Our communications have improved substantially. There was a period of adjustment initially, and we have revisited the process after 1 year. We view this formalized mode of communication very valuable.
To address quality outcomes, we need data. Each F-1 car is fitted with electronics and telemetry to transmit data on every aspect of the car and driver. Each race generates terabytes of information. That information allows the team to make improvements to the cars. The cars have become faster, safer, and more efficient than ever.
We cannot innovate and improve without investment. To use the role of the National Institutes of Health in the development of ventricular assist devices from 1964 to 2005 as an example, approximately one billion dollars has been invested. By comparison in 2006, Formula 1 racing sponsorship was $2.7 billion for 11 teams, 22 cars, and 18 races.16 What we invest in health care research pales by a comparison with commercial enterprises.
So what is innovative about all of this?
In 1962, Everett Rogers, in Diffusion of Innovations, described the percentage of those who were innovators (2.5%) and early adopters (13.5%), with late adopters and laggards at the end of the line.17 This society of innovators represents the top 16%. Our processes need to be in alignment with our rate of innovation of technology and techniques. The future of cardiac sciences is moving toward interdisciplinary teams in clinical care and toward patient-oriented research in which each member is accountable to each other and to the patient. This necessitates a convergence of people and ideas. This is manifest by the convergence of people and processes in the right facility with the right technology around the patient. If we keep patient-centered care as the focus of all of our conversations, we will take the high ground in advocacy for heart care with hospitals, governments, and funders.
In Histoire d’un Crime, Victor Hugo once stated, “No army can defeat an idea whose time has come”18 (On resiste a l’invasion des armees; on ne resiste pas a l’invasion des idées).
I do not know if the idea of interdisciplinary cardiac care or convergence or the heart team’s time has come. I am, however, certain that it is long overdue.
Albert Einstein believed that “Anyone who has never made a mistake has never tried anything new” and that “imagination is more important than knowledge.”
This society and its members are imaginative and intrepid in the pursuit of innovation.
I am proud to be a member and honored to be this year’s president.