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Think Globally

Tuesday, December 12, 2000

The relationship between the attending physician and the treated patient is of a very high order and is best described by the French definition "Le Colloque Singulier." The "Colloque" suggests an equality between the two partners of the relationship and also conversation as the most intense force of interaction. The inequality in medical expertise and resources is no objection for equality in the relationship. The "Singulier" stresses the uniqueness, the intensity and the particularity of this relationship.

The "Grand Patrons" of medical teaching have progressed medical care by combining their clinical intuitions, insights, and phenomenal memories with strong leadership. They were our role models for future careers. We learned to listen and then followed their advice, most frequently because we were forced to, but their advice was also often true. Medicine was art.

The very personal relationship with our patients and the character molding of our teachers has helped each of us to develop a very individual style of practicing medicine. We focused on the way we worked as individuals and tried to optimise this method to reach our expectations, most often again personal ones as quality of care, satisfaction, career or reward (sometimes even in different sequence). Physicians were artists. It was the era of unidirectional education and unidirectional media as radio and television.

I had the privilege of working with IBM in the sixties. Their logo was "Think;" one could find this logo on every desk on every wall. The sixties made us "Think" and our cardio-thoracic surgery profession had intellectual leaders as John Kirklin, who made us think about every aspect of our profession. These leaders stressed thinking about medicine more as a science and less as an art. They demanded evidence. Leading all medicine, the cardio-thoracic community pioneered individual quality control. Communication became interactive gradually and interregional travel became affordable.

Evidence-based medicine replaced the idolatrous approach towards the physician. Surgeons were recognized as mortal, just as their patients. The palliative aspects of many of our therapies and the impact of co-morbidity reduced often the theoretical benefits of our therapies. Physicians, obsessed with quality of care, generated knowledge about the components leading to optimal care and have proven that system failures were more frequent than individual failures.

Similar evidence originated in the quality-driven domains of the non-medical industry. We learned to understand the importance of systems and the way individuals function within these systems. We started looking around us towards the systems in which we function. The "Think" matured into "Think Locally." We included, in our quality control procedures and analyses, elements describing our operational systems. Quality control became a departmental or institutional issue. Our ambition was to make the department or the institution the best performer. The physician was happy and proud about his work.

In the late nineties, communication became fully interactive. One could travel in a single flight over nearly half of our globe and have large documents circumnavigate this same globe during the time it takes to drink a cup of coffee. The cardio-thoracic community also pioneered in this communication -- not regional or national but for the first time global. It did this by creating CTSNet. For the first time ever, medicine talked the same language and shared the same resources from continents to continent. Those of us running point in this path-finding patrol have experienced unprecedented emotions. We learned to accept differences and learned to gain from these differences. The general idea was not to provide information and open-line broadband communication technology to some happy few, but to create a repository of knowledge and technology resources for all cardio-thoracic surgery practitioners and organisations of this globe. An unprecedented optimisation of financial resources was obtained in a scientific domain. The major industrial players in cardio-thoracic surgery have understood this exceptional opportunity and are guaranteeing the financial stability of CTSNet.

Similarly, the cardio-thoracic community pioneered in regional and supra-regional quality control. With this pioneering also came problems generated by linguistic, cultural, philosophical and emotional differences as well as variations in available resources. Those of us travelling through Europe, and helping our colleagues in these confrontations, have discovered that the issues are more similar than dissimilar. Every region or country developed its own "quality" language using its own datasets and its own algorithms. They have accomplished this with their own resources, but, at the same time have consumed them.

Our colleagues have all discovered the urgent desire of politicians and health service purchasers to control the quality of our medical production, thereby sometimes forgetting the scientific basis of outcome analysis. The scientific organisations searched across their regional or national borders for help in this confrontation. They have similarly realised the limitation of their resources in this labour-intensive venture. Finally, some areas of the world have minimal or no medical resources, often limited to the privileged in these communities. How can we be truly happy about the quality of our work if billions of people are without medical resources?

A positive offshoot of this resource limitation was that it led us to redefine quality control. Quality control should not be the selection of the "best" institution, because this involves logically the penalisation of the "lesser" institutions, thereby in all likelihood reducing access to care. Quality control should be the gradual upgrade of the cardio-thoracic surgical systems in the region or continent.

The final goal of quality control is the optimisation of, access to, and availability of health care.

It is obvious that we need a global approach and need to repeat the CTSNet effort for quality control of cardio-thoracic surgery. We will need pathfinders again, but CTSNet is there and can help us. We have to share all our resources, in information technology as well as in quality control. Some us can provide material resources; others will provide intangible resources.

The globalisation of quality control will start by accepting one worldwide dataset for adult, one for congenital, and one for thoracic surgery. Our leaders in this domain, Fred Grover (STS), Bruce Keogh (EACTS), and Shinichi Takamoto (Asian Association) have already accepted this goal and will finalise this urgently. The next step will be optimising globally data collection, storage, and analysis. Since most European or Asian centers cannot afford the high annual costs of appropriate departmental software or afford the costs of national projects of web transmission of these large and confidential data streams, CTSNet will have to provide a solution.

Having a single dataset does not mean a single quality equation. With a single equation there would not be "a Colloque." Differences in operational systems and resources will induce different equations related to these systems and resources. Reducing the number of data warehouses would again optimise resources. What a challenge lies ahead!

The practice of medicine has only sense if we practice this "Colloque" with all our colleagues, with their systems, share our resources and "Think Globally."

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