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J Thorac Cardiovasc Surg 1994;107:331-0337
© 1994 Mosby, Inc.
Presidential Address |
Stanford, Calif.
From the Division of Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
Address for reprints: James B. D. Mark, MD, Stanford Medical Center, CVRB 207, Stanford, CA 94305-5247.
I first want to thank all of you, members and guests alike, for your warm welcome. I wish particularly to thank the members of The Western Thoracic Surgical Association for the honor of being elected to be your president. It is an important highlight in my career and I am genuinely grateful.
I am a most fortunate man. First of all, I had marvelous parents. They are both gone now but their inspiration lingers on. I have a wonderful wife, children, and grandchildren. Along the way I have been associated with first-class educational institutions—Vanderbilt, Yale, and Stanford. We live in a great place. I enjoy my chosen professional field and I occasionally have a really satisfying round of golf. Who could ask for anything more?
It is not often that one has an opportunity to speak on any chosen subject to an important audience that is more or less obliged to hear the speaker out. The late Andy Warhol said something about everyone having the spotlight for 15 minutes or so during a lifetime. Referring to sermons, my father said, "No souls are saved after 20 minutes." I cannot promise 15 or 20 minutes, but I will try not to wear out either your cerebral or gluteal hemispheres.
I have chosen for the topic of my talk, "If I Were King." What would I do if I were really in charge of important things in the lives of all of us? The first thing I would decree would be, of course, world peace. I would ban all nuclear weapons and, as a matter of fact, I would ban all interpersonal violence. I would see to it that everyone in the world is clothed and housed and fed and healthy and that somehow there won't be too many of us in the future.
Once all of that is done we can move on to the easy ones, the future of health care in the United States and the future of graduate education in thoracic surgery. We'll start with health care.
I believe everyone would agree that we in the United States have the best medical care in the world, if that is defined as the energy, the brain power, the man and woman power, and the technology to provide all the medical care available to any sick person. What we do not have is a system of health care.
You do not need to be retold that medical care in this country is too expensive. Right now it is an $800 billion a year item, more than $3000 in expenditures for medical care for every man, woman, and child in the United States. One has only to check any television news program, newspaper, or magazine to realize that major efforts are underway to curb health care expenditures. It is a certainty that whatever these changes are, they will have a jarring effect on the practice of medicine as we know it today and particularly on the practice of thoracic surgery.
If we really have the best medical care in the world, although it is extremely expensive, then we ought to be the healthiest people in the world. The simplest measure of health of a society is length of life of its people, although there are certainly many others. If length of life is a measurement, let's see how we have done for all this money. We are twentieth in the world in infant mortality, ninth in the world in life expectancy at birth, and first in the world in life expectancy once one has reached the age of 80 years.
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It is entirely possible that we are not spending our health care dollars wisely. It seems incongruous that we continue to open neonatal intensive care units while denying prenatal care to over 
millon expectant mothers each year. It seems equally incongruous that on any given day we are willing to spend many thousands of dollars on the care of a patient in an intensive care unit for whom we were unwilling to pay any amount for preventive care in the months or years before that hospitalization.
In the words of Richard D. Lamm, 1 former governor of the state of Colorado and presently director of the Center for Public Policy and Contemporary Issues at the University of Denver, "Our medical genius has outpaced our ability to pay for all we are capable of doing." As a by-product of this plethora of technology and surplus of physicians, the expectation of the public has been raised to the point where everyone seems to expect immortality. Some Californians think that if you drink enough white wine and eat enough salmon you will live forever. In contrast, people in Great Britain are much more likely to accept sickness and even death as a part of life. Here we are willing to spend more for smaller potential rewards. We may not be able to do so much longer.
So what do we do? Let's look at some of the possibilities. We must accept the fact that there are too many hospitals and hospital beds. Perhaps closing one third of hospitals would result in significant savings by consolidation of services, elimination of duplication, and the like. Certainly we do not need 160 hospitals nationwide carrying out heart transplantation when a quarter of that number would do.
Over the years we have talked about factors influencing the rising cost of health care and tried several solutions, all of them unsuccessful. Training more physicians in the 1970s in the hope that market forces and capitalistic competition would bring costs down did not work. Doctors did not respond to market forces. Between 1960 and 1980 the number of medical students doubled. In 1981, the Graduate Medical Education National Advisory Committee report predicted an impending surplus of 50,000 physicians. So much for market forces and planning in medical education. Regulatory forces in the 1980s have been no more successful. Expenditures on medical care as a percentage of gross national product and of federal expenditures continue to rise. Tax funds pay well over 40% of the nation's health bills.
Can we really improve health and save money by paying more attention to pregnant women and to young children and by stressing healthy behavior in the population at large? I suspect that we can, but the savings may not be realized for a generation or more. In the meantime, sin taxes, stiff tariffs on tobacco and alcohol, could be used to pay the increased financial burden. They would provide revenue, target the proper payor, and maybe improve health all at once. It just does not seem right to use tax dollars to supplement the income of tabacco farmers while this product continues to kill many hundreds of thousands of Americans yearly. Similar contradictions abound.
As a nation we seem to be attached to the concept of coverage for catastrophes whether they be health, life, fire, accident, home, or natural disasters. In some of these areas it may be better to spend money up front in preventive care or maintenance and be willing to wait to realize long-term savings. Certainly prevention of some illnesses beats their treatment by a mile. Poliomyelitis, tetanus, and diphtheria are just a few. Why not heart disease and lung cancer, too? The American public cannot eat too much and drink too much and smoke and expect to cure the resultant problems by having catastrophic health insurance. That just will not work.
At the present time we have no system for measuring the effectiveness of medical care or comparing outcomes between different approaches or by different institutions. If we are unable to carry out these relatively simple tasks, how are we to be able to compare various health care strategies? It is mandatory that a system of measuring outcomes of medical care be developed. Only then can we test the effectiveness of different approaches to medical care, thereby seeking improved outcomes and getting the most "bang for the buck." The end result probably will be more regimentation in the way we take care of patients, "practice parameters" they are called, but if such regimentation results in better outcomes it will be difficult to argue with the approach.
It is increasingly obvious that we have reached the point where expenditures for health care are in competition with other worthy expenditures. Expenditures for housing, education, handgun control, prevention of teenage pregnancies, and improvement in the environment are important competitors for money spent on improving health. We need to educate our children and build roads and have good housing and safe streets. These worthy objectives cannot be reached partly because we are spending those dollars on medical care, some of which may be inappropriate. Why should the best building in town be a half empty hospital and the worst building in town be an overcrowded school? We cannot remain a great nation by overtreating our sick and undereducating our children. 1 As physicians, we have thought about the hospitals. As parents and grandparents, we had better start paying more attention to the schools. We may have to stop spending hundreds of thousands of dollars to prolong life a few more days or weeks and start spending more to give our children and grandchildren a proper start in life. Governor Lamm has referred to our present method of spending as "intergenerational larceny." 1
This brings us to the dreaded "R" word 2—rationing. In this country we have so readily accepted rationing on the basis of price, and to a lesser extent on geography, that it is difficult to understand how proposing to ration medical care causes such a furor. As in the state of Oregon, the proposal would be to ration procedures and treatment of some diseases rather than ration people out of the system. At the present time we are spending money on medical care at a level that we cannot sustain or afford. We will be forced to provide less stuff for more people or more stuff for fewer people. I am confident that we will do the right thing and cover everyone at public expense for a basic package of medical care at a price that unfortunately will please neither provider nor payor. Anything over that will be bought by after-tax dollars directly or through insurance by those who can afford more. This is a two-tiered system but not unique. No matter what the system is, everyone cannot get "presidential" medical care. Consider carefully that the alternative to sensible rationing will be further ratcheting. The increasing expenditures for medical care are under intense scrutiny and will be controlled somehow. That you can take to the bank.
One of the problem groups in this complex, cost-conscious medical world is, unfortunately, cardiothoracic surgeons. We treat life-threatening and death-dealing diseases, most of which occur late in life. Our interventions, both diagnostic and therapeutic, tend to be expensive. We do save lives, but at fairly significant cost. How much better it would be to prevent lung cancer or coronary artery disease than to spend a great deal of money to treat it. That would, of course, put us right out of business. However, my guess is that everyone of us is safe on that score. It takes a long time to prevent lung cancer or atherosclerosis.
As medical care becomes more and more the business of the public, physicians' incomes have been and will be under close scrutiny. If one does not count professional athletes, physicians are the highest paid professionals in America and cardiothoracic surgeons are at or near the top of the list. However, we do not want to justify the cynical definition of a profession as "a group of individuals largely, if not solely, dedicated to preserving their own status." 3 We have to demonstrate a broader view than that. There is pressure to redistribute doctors' fees so that the primary care and cognitive groups receive more, and the procedure-oriented specialists, such as ourselves, receive relatively less. I can see the day coming when a lump sum will be paid to all providers involved in a patient's illness or care and the providers will be responsible for divvying it up. This, then, leads directly to capitation, which is payment for illness before it occurs. That's swell from the marketing point of view. But even those who promote capitation talk about risk-sharing. This means that no one really knows if it will work. In my opinion, capitation will work only if physicians are receiving a salary and the plan, or middleman, owns the hospitals and can control costs. Kaiser Permanente is a decent example of a capitated system that works. Any other capitated scheme has lots of holes.
Let me digress for just a moment. I am sure you join me in taking issue with the basic concept of cognitive versus noncognitive physicians. I prefer Isador Ravdin's concept that "a surgeon is a medical man and something more," taken further by Julian Johnson to say that "a thoracic surgeon is a surgeon and something more." 4 No matter whether that is right or wrong, physicians get little sympathy with regard to income. And if it is true that we are the highest paid professionals, school teachers are the worst paid.
Now that I have your attention if not your applause, let me question one of the sacred cows of health care insurance and an integral part of Alain Enthoven's managed competition concept, and that is having medical insurance provided through the workplace. I thought I was alone in wondering about that. I was pleased to see in the April 7, 1993, issue of the Journal of the American Medical Association that Victor Fuchs, 5 in a commentary piece entitled, "Dear President Clinton," said, "We must disengage health insurance from employment."
Let's go back to managed competition itself for a moment and consider why it has become so popular politically. I think the Democrats like it because it is managed and the Republicans like it because it is competition. Nothing else about it is quite that easy to understand.
Having 1500 or so insurance intermediaries involved in health care is an additional problem of the present system. Even at best, they consume too much of the health care dollar, over 20% by most estimates, certainly more than in other countries. It would be much more convenient and less costly to have a single intermediary through which the health care dollar flows between patient and doctor. The big problem is that that intermediary would almost certainly be the federal government alone or, even worse, aided by the states. The government is a major player in health care whether we like it or not. Health care expenditures coming from Washington are far greater than money spent for education or defense. The Feds will not go away. Unfortunately, our federal government has never, to my knowledge, shown that it can be more efficient or less costly or more understanding or more compassionate than just about anything. So, payment through a single intermediary remains a problem. Maybe there could be a government-chartered independent company like Amtrak. Maybe lots of things. In any case, that intermediary is either the government for half of health care expenditures and hundreds of insurance companies and separate plans for the rest or else the government alone with a single basic plan of health care coverage. This is not an easy choice. I would be inclined to give the government one more chance.
Early in April of 1993, the government health task force in Washington proposed a health care card that would document the eligibility of every individual in the country for access to a basic health care package. This card was one of many trial balloons floated by Hillary Rodham Clinton and her task force. There were actually so many trial balloons over Washington during the spring of 1993 that one could not see the sun for weeks on end.
All of this may appear to put physicians in a difficult or even untenable position. How are we to provide the best medical care for our patients while still trying to save money for society? Quite certainly we should continue to take care of our patients one by one in the most skillful and attentive way we know how. Nothing should interfere with that relationship. The physician's role should be unambiguous, the best for his or her patient. He or she should use common sense and compassion as well as medical knowledge with neither the clock nor the dollar bill as a guide, only the patient's welfare. Fuchs, 6 the economist, has said, "The commitment of the individual physician to the individual patient is one of the most valuable features of American medical care." This does not necessarily mean that one should order every test and do every procedure available. Remember, judgment is an essential ingredient of medical care. Sometimes the best care is letting a patient die gracefully and naturally and, in popular parlance, with dignity. As a colleague of mine once said, "When the good Lord puts his hand on your patient's shoulder, you take yours off."
How, then, do we as physicians and surgeons play a role in determining health care policy? Quite obviously we are not going to be allowed to do that alone, and if recent history is any indication, we may not be allowed to do it at all. We as physicians seem to have few friends in Washington these days. I fear we are looked on as just another advocacy group looking out for our own interests. We must rise above that. We must take the high road. We must be statesmen rather than merely advocates. As physicians caring for patients, the interest of the individual patient is paramount. Again, there should be no ambivalence in that role. However, we must be able to change hats and participate with government officials, the public, and other experts in other health care fields and medical economists in making important decisions in public policy as they relate to health. If all of these things are successfully carried out and priority decisions are made at a societal level, it may even make our job at the bedside easier and more effective.
There are a number of other factors that influence the cost of medical care. We point with some justification to malpractice specifically and lawyers in general as a source of increased cost of medical care. The cost of malpractice insurance is easily identified. The cost of defensive medicine is more elusive. We do know, however, that in the United States with about 5% of the world's population we have about 70% of the world's lawyers. There are ten times as many law school graduates each year as there are medical school graduates. 1 If each new doctor generates hundreds of thousands of dollars in incremental costs, how much is generated by each new lawyer? We could be talking about real money here. Fuchs 5 points out that the cost of drugs is not as influential as it seems to be. If drug company profits were cut in half, savings to patients would be in the range of 1% of the cost of medical care. If physician incomes were cut 20%, and they probably will be, the overall saving would be in the range of 2%. We may be a part of the problem but not, in fact, such a great one.
We have yet to address the question of specialists versus generalists, the latter being defined as family practitioners, pediatricians, and general internists. I am not convinced that having more generalists would save money unless they were acting mainly as gatekeepers or if they did what specialists do, only more cheaply. Seeing a generalist may be just an additional step on the way to seeing a specialist. Using patients with lung cancer as an example, I am not sure the generalists are even sending the patient to the right specialist. Nonetheless, there will be increasing pressure to curtail the training of specialists, and we are a prime target. Personally, I would first take a crack at the procedure-oriented internists.
In our desire to accomplish some things, we often forget others. In this instance, I am thinking about two of the very special accomplishments of the American medical establishment that we must make every effort to preserve.
The first of these is medical education. Our system of medical education at the undergraduate and graduate levels is the envy of the world. We are the acknowledged leader and pacesetter. It would be more than a shame if, in our anxiety to save money, we should sacrifice the educational system. It would be short-sighted and eventually totally destructive. Unless we plan and educate for the future, we cannot possibly continue to lead the world in medical care.
Second, and closely related, is research. Our scientific research establishment, led by the National Institutes of Health and academic medical centers nationwide, is again the envy of the world. People everywhere look toward the United States to be the leader in biotechnology research and development as well. The world literally depends on the products of our investigative work. To stifle these efforts would have far-reaching negative fallout.
If I were the health care king my plan would include the following.
The major fear associated with the institution of such a plan is that, even if this resulted in less payment for medical care in the long run, it would be far more expensive in the short term and would lead to the political death of anyone who supported it. I am not a medical economist, but I believe that if universal access, including coverage of the 37 million persons now without health insurance of any kind, were accompanied by appropriate rationing and sin taxes, the short-term financial pain would be minimized and the politicians who put such a plan in place would at least have a fighting chance for survival.
All of this, naturally, sounds pretty good to me. However, as Uwe Reinhardt, the Princeton economist, has said, "The devil is in the details." He is undoubtedly right. I will leave the details to others.
Let's spend a few minutes thinking about the future of the field of general thoracic surgery, presuming that there is such an entity. I think there is. The entire field of thoracic surgery less than 60 years ago was what we now call general thoracic surgery. Interest in the specialty was spurred by the Empyema Commission under the direction of Evarts Graham during World War I. Surgical treatment of bronchiectasis, tuberculosis, and empyema dominated the field. Improvements in anesthesia and perioperative care, the development of antibiotics and antituberculous medications, and the performance of a pneumonectomy for cancer of the lung by that same Dr. Graham almost brought the field to maturity in the 1930s and 1940s. Then along came Gross and Blalock, Gibbon, Lillehei, Starr, Favaloro, Shumway, and many others who ushered in the exciting and still dazzling field of cardiac surgery and ultimately cardiac transplantation. Thoracic surgery became cardiothoracic surgery and what was previously thoracic surgery became general thoracic surgery, or, God forbid, noncardiac thoracic surgery. With rare exceptions, cardiac surgeons paid little attention to general thoracic surgery, and, with few exceptions they did not advance the field. A handful of surgeons in academic medical centers and cancer centers restricted their work to general thoracic surgery. They taught the residents and pushed back the frontiers while simultaneously fighting encroachment from general surgery, pulmonology, oncology, and otolaryngology. The tide of cardiac surgery was in some ways intimidating, certainly overpowering. Should general thoracic surgery go it alone as a separate training program following general surgery, leading perhaps to the much-maligned certificate of special competence or added qualification in the field? The Liaison Committee for Thoracic Surgery, of which I was a member for several years, addressed this problem and reported its findings and recommendations to its parent societies, The American Association for Thoracic Surgery and the Society of Thoracic Surgeons, on more than one occasion.
The committee was composed mostly of "lumpers," those who wished to maintain cardiothoracic surgery as a single specialty. I must confess that at the outset I was a "splitter." I thought that the field of general thoracic surgery, those who practiced the specialty and the patients for whom we cared, would all be better off if general thoracic surgery was made a separate and identifiable field. I have changed my mind, although I am not certain that I was wrong. The gradient against which one would have had to work to accomplish this cleavage and then nurture to maturity the new entity was just too great. Maybe the argument for the split was just not compelling enough. Now the field remains unified, and properly so. The Liaison Committee for Thoracic Surgery has been dissolved and the problem has been turned over to the Thoracic Surgery Directors Association for oversight and safekeeping.
End of story? I think not. Forget outside pressures from the federal government, funding sources, and the public. The whole field of surgery, including but not limited to cardiothoracic surgery, is changing so rapidly that adjustments in training programs in cardiothoracic surgery must occur. Otherwise we will become petrified and lose our position of leadership as "surgeons and something more."
At the moment, the main concerns surrounding thoracic residency seem to be, first, on the link to full training in general surgery, and, second, on time, or how many years an individual should remain in training in cardiothoracic surgery. Five years or more of general surgery followed by 2 years or more of cardiothoracic surgical training adds up to a lot. In our desire to shorten the total length of training, the American Board of Surgery has been asked to shorten its mandatory number of years in grade. The generic reply has been that they wish to train general surgeons, not just prepare residents for training in cardiothoracic surgery. If we in cardiothoracic surgery wish to shorten the total number of years while still adding a year in thoracic surgery, why don't we just quit requiring board certification in general surgery before residency in thoracic surgery?
Again, we deal with lumpers and splitters and focus on numbers of years. Instead, we should consider more carefully the educational content of our residency programs, both in general and in thoracic surgery. There are parts of general surgery that are of more value than others in the education of a thoracic surgeon. In turn, the so-called index cases in the training of general surgeons, the Whipple procedures and abdominoperineal resections, for instance, may not be so important to budding thoracic surgeons.
Instead of remaining so independent and resistant to change, the American Board of Surgery and the American Board of Thoracic Surgery should get together and focus on the educational content of training programs rather than on their length. Surgical skills would be gained in areas of interest and usefulness. The few Whipple procedures that I did during residency added to my surgical skills and certainly added a few notches on my belt, but maybe it would have been better if someone who was more likely to be doing those operations for the rest of his or her working life had done them rather than I. Similarly, it may not be as important for the resident going into the community practice of general surgery to have done pulmonary or even esophageal resections during residency training.
The point to be made is this. Our field is evolving. There is a new interest in general thoracic surgery, spurred in some part by the development of lung transplantation and even thoracoscopy, but also nurtured by the realization that we still have a long way to go in understanding the causes and identifying the best cures for lung cancer. Because so many of us in general thoracic surgery are nearing the ends of our careers, I think there will be many opportunities in academic work and in private practice for physicians devoting their professional lives to the field of general thoracic surgery. It is my belief that, to train these individuals best, there will need to be adjustments in training both by the American Board of Surgery and the American Board of Thoracic Surgery. A similar sentiment has been expressed in the recently published proceedings of the Joint Conference on Graduate Education in Thoracic Surgery. 7 I understand that the American Board of Surgery and the American Board of Thoracic Surgery have been and will be discussing these matters. 8 Having been an examiner for both of these boards, but having been a member of neither, still having been a member of a medical school faculty teaching residents in both fields on a daily basis for 33 years, I believe I can speak with some background of experience if not authority.
My suggestions for training in general thoracic surgery are as follows.
There you have it. This is a whole new concept, perhaps not unique, outlining education in general surgery and in thoracic surgery. The concept will probably be politely applauded by some, embraced by a few, and instituted by even fewer. In the words of Niccolo Machiavelli, quoted by Claude Organ 9 in his editorial titled "The Future of General Surgery," "There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old condition and lukewarm defenders in those may do well under the new."
I cannot finish without at least giving a nod to something about which I feel strongly, and that is the often-referred-to, somewhat-less-honored, doctor-patient relationship. As physicians specialize further and particularly as paramedical personnel increase in number and their role expands, there is a danger that the doctor will move farther from the patient. His or her former role is filled by someone else or no one. This would be a tragedy of major proportion should it escalate. I can think of no quicker way to turn medicine from a profession into a trade than to depersonalize the doctor-patient relationship. Like pornography, as described by Justice Potter Stewart, the doctor-patient relationship may be difficult to define but easy to identify. It is based on personal contact and interest and on continuity of care. It is destroyed by a shift mentality and by lack of identification of just who is the patient's doctor. One can point to those of us in academic medicine, particularly, because we seem to have many other facets of our work that compete for our time and interest. If these competing obligations, be they research, teaching, administrative work, or other equally worthy endeavors, keep us from caring for our patients in a manner in which we would like to be cared for, then we have lost our favored position as caregiver, mentor, healer of the sick, and role model for young people to which we all aspire.
This has been a special day for me. If something that I have said sticks, grows, and bears fruit, so much the better. To quote Robert Louis Stevenson, "The world is so full of a number of things, I'm sure we should all be as happy as kings." 10 I feel that I have been king for a day, and I thank you all sincerely.
Footnotes
Read at the Nineteenth Annual Meeting of The Western Thoracic Surgical Association, Carlsbad, Calif., June 23-26, 1993. 
*Johnson & Johnson Professor of Cardiothoracic Surgery; Head, Division of Thoracic Surgery, Stanford University School of Medicine.
References
This article has been cited by other articles:
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  K. W. Jones TWENTY-FIVE YEARS OF EXCELLENCE: THE LEGACY AND THE CHALLENGE J. Thorac. Cardiovasc. Surg., February 1, 2000; 119(2): 203 - 209. [Full Text] [PDF]
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