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Primum Non Nocere

Thursday, November 16, 2000

Changes that are currently sweeping over the world are having a great effect on the professional lives of doctors and especially cardio-thoracic surgeons. Perhaps the most important of these trends are the everyday use of Information Technology (IT). Also important changes are demands for better cost-efficiency in medicine, a declining respect for the medical profession, and globalisation.

The use of information technology, perhaps the most influential of the four major trends has vastly facilitated the collecting, analysing and spread of data; it allows us to communicate speedily and effectively on a personal basis via e-mail and on a collective basis via homepages. Thus IT is an extremely important tool for all groups of people with common interests, and offers professional groups a remarkable opportunity.

Increased demands for better cost-efficiency are due to the fact that medicine is consuming increasing proportions of the gross national product. Put in another way, we are spending more money than society can afford. There is a direct relationship between buying power of the individual (on a country level) and the proportion of the gross national product (the wealth of the country) devoted to medical care. The relationship on a worldwide basis has an r=0.77, which means that it expresses a basic human law. The richer we get, the more we are able and prepared to spend on ourselves and to assist our fellow citizens (via taxes) in medical matters. Because of the outstanding success of modern medicine, it itself has become a fiscal threat to society. Medical care is and can never become completely satisfied (from the financial point of view). The needs of medical care will have to be prioritized in such a way that it does not threaten other worthy and needy sectors of society. Thus resources made available for medical care must be used in the most efficient ways possible.

The decline in the public's respect and esteem for doctors needs explaining. Only half a century ago, a professor of Medicine was almost an Oracle of Delphi. He could express a view and be cited and believed in almost any area of human life. The village doctor in many countries around the world was one of the pillars of that society. When I became a student of medicine, I noticed a change in reverential attitude towards my knowledge and me. We know now how little was the evidence on which these colleagues -including myself- based their opinions. Very often they exerted power that had been given them almost in the same way power was earlier given to priests and medicine men in more primitive societies. This decline in respect and esteem is something that is seen in almost all the learned professions. Authority no longer is automatic in the title, it has to be earned on an individual basis, again and again for every new customer/patient. In our world of Medicine this trend is probably good in the long run as it will lead to patient empowerment. But it needs some adapting to.

The last trend is globalisation. Medicine is practiced between patient and doctor and influenced by local culture and tradition. However, the needs of the doctor as a professional can be addressed on a global scale. The trends of private industry to become global in their attitudes will be adopted by many professional groups. The benefits to become a global enterprise are many and far-reaching. Some examples: it is possible to reach the majority of a profession's members around the world for an important message, for members to express themselves on a collective basis via questionnaires or votes, to increase and promote the spread of scientific thinking and of new scientific material, to create new knowledge on a regional or world-wide basis via registries, for industry to expose their products world-wide and for individuals interested in the same small topic to form discussion groups. Some major advantages in running a global Association are the advantage of economies of scale in developing and using the necessary administrative software, the streamlining of the administrative work and the ability to reach all members quickly and completely.

What are the more far-reaching effects of globalisation? In the case of private industry and economics, the power has shifted from nations to sectors across nations. Big conglomerates and financial forces may now be able exert powers that will change conditions throughout a market driven world. Will professional societies do the same? Will they be able to standardize our language and terminology world-wide; will they be able to harmonize education in setting standards; will they be able to formulate the basic and ideal requirements for practicing medicine; will they be able to express themselves as regards the organisation of a department; will they be able to support the individual member under allegations of misconduct; will they be able to help national authorities, departments and surgeons to improve quality; will they be able to create and uphold an official recognition of Good Practice? Only the future will tell.

What is very obvious, in my opinion, is that we must be active in the shaping of the future. The creation of CTSNet has brought cardio-thoracic surgery to the forefront of this development. We now possess a tool that -well used- can help us in adjusting to, and taking advantage of and responding to these new trends. Cardio-thoracic surgery is currently in the best position to respond to these trends. We are also one of the specialities that are most affected by these trends. The allegations towards cardiac surgeons in the UK and Germany are ominous signs. The perpetual messages about budget cutbacks are others. In other, more market oriented countries, the reimbursement for each treated patient has decreased not insignificantly.

In my opinion, we should concentrate on what we are best at doing, which is to operate and to care for patients before and after the operation. Nobody else can perform that highly desirable service. This is our strength. We should also be able to show that we do this well. In other words, we should put our own house in order and be able to show that we have done so responsibly. In my opinion, patients, relatives, the public at large, financing systems and politicians are all interested in knowing that we do the right thing (indications), that we do it right (quality) and that we do it at the lowest possible cost (cost-efficiency). If we can show this, the trust will be there and we have a greater chance of being left in peace to go our way. We will have the support of our patients.

It is a fact that the systematic knowledge of indications is a poorly developed area within medicine. There has been precious little research about how indications are formulated and implemented. As the indication is the main factor influencing the final financial burden of a certain medical activity, it is actually surprising that so little has been made in this area. The indication has been largely left to the medical professions to decide -and perhaps rightly so. That the indication is vastly differently treated in various countries is obvious from the figure above. The same indications cannot be upheld in a country with little wealth compared with a country with large wealth. Nevertheless, it cannot be stated that doctors in the wealthy country have higher ethical standards than doctors in poorer countries. I believe that we are going to hear much more about indications in the future than we have in the past. Let us then be well prepared for this debate. It is interesting to note that cardio-thoracic surgeons, notably John Kirklin, have instigated some of the few attempts at systematic research on indications. He has taken the radical and in the future probably indispensable step of allowing the computer to help us in deciding the indication for the individual patient. 

It is also a fact that there is still much to do about quality in medicine. Professional quality managers in private industry have expressed a concern that quality management in medicine is not up to their standards. There are lives lost and suffering caused by general deficiencies in our quality management systems. In this regard, we as a profession must take the entire responsibility to get our house in order. Primum non nocere. First, we have to accept that we can do better; second, find out how to do it; and third, accept the responsibility and get the authority to achieve the task. This means getting control over the entire chain of events from the patient leaving his home until he is home again.

The interesting thing is that by defining and maintaining proper indications and by improving quality, cost-efficiency is automatically improved. Thus cost-efficiency in my experience has much more to do with organisation than with surgical skill; with how the team taking care of the patient functions as a whole rather than how the individuals function.

Another effective way of improving quality is to measure it, monitor it and spread the results to the entire team. Just by spreading the results and pointing to the road ahead, the quality measurements will show an improvement. Sometimes it is necessary to instigate a formal project in order to improve, most often not. Another way is to consciously collect data, discuss them with a trusted group of friends and then instigate improvements based upon the discussions about how others have done.

This means that every department should maintain a comprehensive, accurate and probably public registry of its own activities. The data should primarily be used to follow the quality over time. The important thing is to show a direction forward, to show improvement. Only secondarily should the data be used in comparisons with other departments and countries and then only in well conducted registries. Finally, the data should be used for our self-protection. We have nothing to hide. If everything is public there are no scoops.

What can the medical associations do in order to meet the future? They can among other things create the tools by which to work in data collection. The STS Registry for adult heart surgery has functioned for several years. In collaboration between the STS and EACTS, terminology has been agreed upon in congenital heart surgery. A thoracic registry is ready to be launched soon. Other initiatives are in the pipeline. In many of these initiatives the CTSNet plays or will play a major role. Both STS and EACTS have working groups toiling with the task of deciding which way the societies should go. Apart from getting our house in order, however, there are many other things to do. One of the issues is to get a structure for the entire world to work together. The Asian Society of Cardiovascular Surgery has just joined the community of CTSNet organizations, and we welcome them. In South America there is unfortunately no supra-national society, nor in Africa. It would seem highly desirable if these continents could get their act together and join the CTSNet. By having this structure, cardio-thoracic surgeons would be united in an organisation that will provide tools for them but maintain the right of self-determination for individual societies on the continental or national level. One of the beauties of the CTSNet is that it provides tools for communication and collaboration but has no agenda of its own. It looks internationally but serves the national and continental societies. It is a reason and a means for collaboration but makes no demands on those unwilling to participate. It is unselfish and almost free of charge as the original investments can be used for many societies. Thus the globalisation of medical specialities will adhere to the original ideal of the Internet to be non-commercial and generous towards its users.

Another initiative for our societies is to imbue the next generation of surgeons with the goal that they should become better than we in the older generation. This means investment in these young doctors. It means investing in them not only surgical skill but also theoretical knowledge, willingness to learn from others, experience, personal maturity, responsibility as well as knowledge and understanding for other sectors of society. This is especially important for those who take the task of leading a department, act as consultants to governments or work within our medical associations. Also in this regard, the CTSNet will be highly instrumental. The educational tools possible on the net have just started to be explored. To reach cardio-thoracic residents of the world by one lecture, to provide the world with our journals, to use moving pictures and sounds to illustrate case reports, to provide a risk equation with an easy-to-use ready-made software program to download from the net are just some of the features possible already. Detailed and extensive information will be easily available for residents and specialists alike -to the benefit of the patient. However, in order to provide the content of these initiatives we will be dependent on all colleagues willing to participate and create educational material to be featured on the net.

Thus, in my opinion, the four trends of change will influence cardio-thoracic surgery markedly during the coming years. Inasmuch as they are inevitable, we have to adapt. There is much to do for everybody in this adaptation, mainly work towards the patient but also within the hospitals, the financing systems, the national societies and internationally. These are truly exciting times!

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