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SharethisDramatic changes in health care in the past 12 years have affected the lives of most physicians and every thoracic surgeon. As a result, many of us have experienced a sequence of normal reactions to stressful life changes not unlike those first described in the aftermath of the Coconut Grove fire in Boston during World War II. Denial is the first reaction to such events. When reality cannot be denied, anger follows. A period of depression signals the beginning of acceptance of the reality, which is followed by constructive activity to cope with the situation; the eventual outcome is often mastery of the traumatic experience. In our specialty, a few individuals remain hopeful that these drastic changes can be halted through a political process or by intransigence. Many more of our colleagues, however, continue to be profoundly discouraged. They regret that they chose cardiothoracic surgery as a career, and are leaving service early. Some of us are advising young students to go into other fields, and nearly all of us are furious with politicians and businessmen who have apparently sacrificed patient care to market forces.
But, it is also clear that a progressively growing number of young thoracic surgeons are emerging from anger and discouragement and committing themselves to seizing control of their future and guiding health reform by heightened stewardship in their communities and societies, and by formal education in courses and degree programs in information technology, health policy, health economics, leadership and management.
The Alley-Sheridan Fund of The Thoracic Surgery Foundation for Research and Education was established to provide educational opportunities in health care policy matters for cardiothoracic surgeons. The fund has been used to make a generous grant from The Foundation to the Kennedy School of Government at Harvard University to develop an intensive executive course in management and health care policy. Since its inception in 1996, nearly 250 cardiothoracic surgeons have graduated from the course. These surgeons are now becoming a critical national resource through their enhanced understanding of our healthcare system and their new insights into our profession and its role in society. Virtually all of the STS leadership and numerous members of our societal committees have taken the Kennedy course. Their recent success in the initiative to clarify the current five year review of the Medicare Fee schedule reflects the strengthened tactical skills and strategic thinking of our membership. All thoracic surgeons are indebted to Dr. Jack Matloff, who founded the executive course, and Joseph Newhouse, Ph.D., and Miles Shore, M.D. who skillfully shepherd each participant to an increased understanding of the dynamic changes in the health care system, principles of economics as they apply to health care, the political dynamics of health care, public attitudes about health care, methods for improving the quality of care, the rationale for, and the mechanics of managed care, and much more.
A defining moment for me of the ninth and most recent offering of the Kennedy course: Skills for the New World of Health Care was a video presentation by Donald M. Berwick, M.D.,M.P.P,President and CEO, Institute for Healthcare Improvement, entitled "Escape Fire". In his presentation, Berwick emphasizes that physicians must adopt bold goals and new designs to better meet the needs of the patients and communities they serve. His parable of the current health care environment is the account "Young Men in Fire" by Norman Maclean: On August 4, 1949 thirteen smokejumpers lost their lives in Man Gulch, Montana in a fire which didn't behave as they expected. The fire suddenly crossed the forested area of the gulch to a grassland which was territory unfamiliar to the fire fighters. Driven by a strong wind, the fire was traveling at a terrifying rate of speed. Wag Dodge, a senior smokejumper, was the first person to recognize the impending disaster and knew they would not win the race from the fire. The young men were running up a steep slope with the weight of their packs and their tools, which they had been taught never to drop. In a remarkable moment, Wag Dodge took a match from his pocket, bent down, and lit a new fire---which gradually spread uphill and provided a new burned area with no fuel for the oncoming inferno. Dodge stepped into the middle of the new burned area and called for his crew to join him. No one followed him and they all ran past the solution to their deaths. Wag Dodge survived, unharmed, and had unknowingly created an "escape fire" which would soon become a standard part of the training of fire fighters.
Berwick acknowledges that he really didn't understand the full meaning of "Young Men in Fire" until, years later, when he read University of Michigan scholar, Karl Weick's work: "The Collapse of Sense-Making in Organizations, The Man Gulch Disaster". Sense-making, according to Weick, is a process through which a world is given order and is interpreted, within which people can find an orientation or purpose, action, or sense of possibilties. Organizations unravel when sense-making collapses, when people can no longer supply meaning, when they cling to interpretations which aren't working any longer. For example, the Man Gulch smokejumpers became isolated, unable to communicate with each other, and they panicked. Like the smokejumpers, asks Berwick, has the health profession experienced a sudden loss of meaning and are we clinging to interpretations which no longer work? Is health care in the United States unraveling? Says Berwick, "For physicians who cling to the old tools, the sense-making will dissolve. They will be driven up a slope too steep and too far for them to make it. For the rest, the possibility of invention will remain intact, and the opportunity to make new sense isn't just going to open avenues of escape, but new vistas of achievement"
The specialty of cardiothoracic surgery confronts its own particular challenges, and, may be at risk for a collapse of sense-making. A formidable threat is the steadily diminishing payment for specialty care in general and for cardiothoracic services specifically. Further, the changing definition and scope of the specialty has led to the emergence of "splinter interest groups" which seriously erode our stature and diminish our ability to speak with one voice. Increasing demand for convenient, cost-effective outcomes (patient focused factories) also lead to division among our members. The status of cardiothoracic surgery is changing relative to other specialties and there are emerging technologies which can duplicate and/or replace our existing efforts. In the long run, we may face a declining demand for cardiothoracic surgery because of alternative medical treatments and the promise of genetic engineering in the future. We must also recognize a lack of practitioner diversity, in terms of minorities and women, within the specialty. One of the most serious threats to the survival of our specialty is a failure of renewal. We no longer have enough USA graduates with the interest and resolve to fill our residency positions. Medical school incentives are directed to primary care, and extended graduate medical funding is in jeopardy. These events, unattended to, will surely present a tertiary health care crisis to the growing geriatric population.
It must also be appreciated that The Society of Thoracic Surgeons --"the face of thoracic surgery"-- confronts unique internal challenges. The traditional professional societal infrastructure, driven by rotating leaders, volunteerism, and membership dues, is being stressed to do much more than it was designed to administer. There are increasing expectations among members, admittedly based on past STS successes, for a greater sphere of support services that are increasingly complex at a time when there is less money and time available for these activities. We have also witnessed an exponential increase in the amount of information required to practice evidence based cardiothoracic surgery, underscoring the importance of STS national database efforts in cardiac, general thoracic, and congenital heart surgery. Finally, globalization of medicine, and surgical technology and standards, is a reality which affirms the wisdom the CTSNet initiative. Significant operating deficits for the STS over the past two years are symptoms of this complex set of challenges, and they suggest an imperative for change. "Staying the course" is not an option for The Society. There is no doubt a raging brushfire is bearing down upon us and we must discard useless tools and discover a safe area if we are to transform hope into constructive action. In my opinion, we must ignite an "ESCAPE FIRE"!
The concept of an "escape fire" for our specialty is clearly embodied in the process and implementation of The Society of Thoracic Surgery Strategic Planning effort led by STS President Jack Matloff. Dr. Matloff initially emphasized that The Society is the only organization in our specialty that fully represents the breadth and depth of the many and varied interests of cardiothoracic surgeons in caring for patients, serving society, and maintaining their competence, in fact, excellence. In April 2000, The STS Strategic Planning Committee began a process to analyze and evaluate current and future directions for the specialty and The Society, including the possibility of going in very new strategic directions. To assure appropriate focus, the steering committee organized a Washington D.C. retreat with an expanded group of professional and industry leaders in August. The interests of the entire STS membership were surveyed electronically with a detailed questionnaire early in the fall. Expectations for the planning process are that The Society will be proactive in responding to challenges and framing the agenda, must be on high ground morally and ethically, and must never compromise our members advocacy for quality care. Finally, the plan will allow for resources to be catalogued and prioritized in a way that will be dynamic and continuous, with programmed, continuing evaluation, re-evaluation, and implementation. Indeed, the plan will be a living guide to future change and planning for our patients, specialty, and society.
As noted above, the strategic plan will remain a work in progress. However several operational principles have become clear: the stated mission of The Society will be "Helping Cardiothoracic Surgeons Better Serve Patients". This simple statement reflects the principle that cardiothoracic surgeons,who constitute the STS membership, have the ultimate responsibility to improve the welfare of all of our patients. With this in mind, The Society can best fulfill the mission statement through the following value focus: Helping members better serve society through the care of patients with cardiothoracic disorders. The STS will: foster a health care environment that best helps meet the needs of patients; provide professional support for its members; increase the value of volunteerism that each member provides; help members expand their sphere of care and influence; and work with other organizations to speak with one voice and purpose for the specialty, for our patients, and for society. To achieve these goals, the STS must build on its traditional and future strengths to take on an expanded and evolving range of services, beginning with a revised organizational structure.
The intent of the strategic plan is to create greater value for The Society's constituents by four strategic initiatives. First, the STS will sharpen its operating focus by separating its current functions into more appropriate operating units while maintaining the traditional STS as the strategic umbrella for these activities. This model will increase the flexibility of The Society to plan for the future and assure its capacity for growth.
Second, the STS will broaden the professional capabilities of its members by facilitating partnerships with uniform organizations, conduct joint educational programs, coordinate communication with industry and government, inspire and promote clinical research trials, and facilitate the growth of collaborative medicine.
Third, the STS will continue to build on initiatives for patient welfare created over the past decade: the National Cardiac Database and the CTSNet. The latter two programs provide a platform for related efforts in which The Society has a comparative advantage related to the intellectual capital its members can bring to the process. Important considerations will be the assessment of the effectiveness and safety of new technologies, training cardiothoracic surgeons in new technologies, and assessing the competency of cardiothoracic surgeons with new techniques.
Fourth, the STS will develop new initiatives for patient education and enlightenment. These public oriented programs would include prevention of cardiothoracic disease, treatment alternatives, and rehabilitation options. The overriding principle of the strategic plan will be to achieve this mission and value focus by emphasizing advocacy for members, patients, and the public.
An exciting opportunity and a critical professional need for participation exists for every member of the STS. We are privileged with the international gold standard in graduate medical education, we are the "go to surgeons" in our community units, and we are an unrivaled hallmark of accountability. A major obligation rests with each of us becoming enthusiastic, concerned advocates of our special heritage. It is, in fact, a recent graduate and new member of the STS who can respond most knowledgeably and effectively to the critical issues facing the specialty. The impact of health system reform will require the practicing thoracic surgeon to become more directly involved in guaranteeing the quality of surgical care in their region. It is equally important that each of us continues to monitor proposed health system changes and make our STS Director of Government Affairs, Robert Wilbur PHD, (robert_wilbur@dc.sba.com) aware of your observations. Energized by my own experience at the Kennedy School, I hope that we all will be able to celebrate a time of unparalleled promise in our chosen profession; will strive to make a personal difference in our professional future; will welcome the opportunity to help our colleagues better serve patients, and will trust little to tomorrow.
"Carpe Diem, quam minimum credula postero." Horace 65-8 B.C.
In my opinion, Seize the day, my friends.
