Surgical Cancellations

I have always thought, and accepted, that waiting for healthcare services was an acceptable compromise for the public healthcare system in Canada, who tries to provide comprehensive services to all its citizens. This contrasts to the US system, which is able to provide nearly immediate service, but only to well-insured members of its society. I have not found the latter to be a “just” proposition. However, what I do not find acceptable, and is deplorable, is the cancellation of patients who have waited for the service Canada has promised to provide.

The reasons for patients having surgical procedures cancelled are protean. I do not have the knowledge or expertise to discuss them all intelligently. What I can point out is that the healthcare system is chronically underfunded. There has also been an apparent lack of foresight related to human resource needs in the system.

Because the healthcare system in Canada is essentially a monopoly, hospitals have no immediate incentive to fix the “cancellation issue”. For the vast majority of patients, there is nowhere else to go for hi-end, tertiary care surgical services. Although, I am NOT an advocate for privatization, I do think that “pay for performance” and competition within the public system could be healthy for patients.

As surgeons, we tend to ignore or minimize the consequences of cancellations on our patients. Yet the effects can be significant. In my field of practice of pediatric cardiac surgery a cancellation affects families financially. Parents have had to travel, find accommodations, and take time off work. They have had to make arrangements for the care of other children in the household, perhaps affecting extended members of the family. There is not always complete financial assistance from the Provinces.

Equally important is the psychological impact of a surgical cancellation. I believe that patients and families prepare themselves mentally for the upcoming surgery, hospitalization, and convalescence (especially the surgery). A cancellation disrupts this mental preparedness and can be psychologically distressing. It makes families and patients feel vulnerable because they are not in control; it leads to uncertainty; and may even lead to doubt about the ability or competence of the system that is supposed to care for them.

Interestingly and thankfully, I have found patients and families very understanding and accommodating. I always apologize on behalf of the “team”. But I have never heard of or seen an administrator of a hospital go and speak with a patient or family about their surgery being cancelled.

Canadians are generally very happy and satisfied with their care, when it occurs. When it relates to surgical cancellations, I think they are being too forgiving and too tolerant of a significant inadequacy in their healthcare. Just because it is free, that does not mean that we cannot demand some measure reliability when it comes to timing of surgical healthcare delivery. “When we say we will do it, we will.”

Academic Productivity and the Annual Report

Recently, a colleague showed me a draft of an annual report of a cardiac surgical program. (The final product is unlikely to be substantially different than this draft.) It outlined the academic activities of the division. It looked quite impressive. However, on closer inspection, many of the publications, abstracts, and submitted publications were of work that was done at other institutions when their junior staff and residents were doing fellowships. Anywhere from 1/3 to ½ of the academic activity was such. My question then becomes, is this an honest assessment or depiction of that division’s academic output?

When a new cardiac surgeon is hired on to an academic division, there are usually research projects in various stages of completion, dangling like participles, from their previous fellowship training. It is reasonable to include these academic activities because they reflect well on those individuals who put in the effort. However, it should be stated clearly that this academic output is derived from efforts at ANOTHER institution.

I believe that this distinction is important because academic output is dependent on the individual AND the conditions at an institution that permit this activity to occur. By not being accurate and clear about where the research was done, this cardiac surgical division is overstating its accomplishments and the report is misleading. This is especially true if the new staff surgeon was not supported financially, or otherwise, during his or her fellowship. At least if the individual was supported during the fellowship, the division could claim some measure of ownership of the research, as it created favourable conditions for the fellow. Unfortunately, support (financial or otherwise) and assurance of employment during fellowship is a circumstance that is all too infrequent.

The situation is similar for residents that are doing their enrichment years at other institutions. Although it can be argued that because the residents are still part of the training program and are being supported, in full or in part, that the academic activity is in some measure part of the Division. Nevertheless, I opine that a clear distinction should be made as to where the research endeavours were made.

For surgeons that take sabbaticals, the same rules should apply.

It is dangerous for a division to be misleading by not being clear. Once the research at other institutions is no longer there, it will appear that the academic output of the division is precipitously declining, leaving the division head having to explain this change to the Hospital or University.

I can only hope that the final annual report from this division, when it comes out, will be more clear about where the academic output of its junior members was undertaken. If this is not the case, some of the responsibility lies in the Hospital or University that do not demand that this distinction be made.

On Meetings: A Loose Ethnography

In my brief career in Thoracic Surgery, I have attended a few major meetings in North America. I have found the experience interesting often, rewarding occasionally, and disappointing sometimes.

The purists would say that the original and true purpose of a scientific meeting is to communicate new data of ongoing or completed research. The objective here is to disseminate new information, as it is on its way to becoming knowledge. Very importantly, it gives the presenter the opportunity to discuss observations and criticisms about their work. I still believe that this is a seminal purpose of the meetings in Thoracic Surgery.

However, with the frenetic pace of science, the internet, and the explosion of information that is available, how is it that the scientific meeting survives to achieve this seminal purpose? I speculate that just like newspapers and books survive, so does the presenter in front of the podium. Nothing can substitute a face-to-face discussion surrounding a question or a problem. True insight into someone’s research is only gleaned this way.

But this is the idealist’s view. In reality, to really judge and critique research, it is necessary to review the published manuscript (and sometimes even then it is difficult). Nevertheless, there is value added in speaking with the investigators.

For me, the research aspect of a meeting is a great source of new ideas and it renews my enthusiasm to support and participate in such research endeavours. This is the interesting part.

Most of us are simple practitioners of clinical thoracic surgery and our purpose in attending meetings is to be educated. Pure research discussions may be of little relevance to the average surgeon because only rarely can the research be applied immediately to clinical practice. It is the educational component of the meetings that attracts many of us. It is an opportunity to listen to expert opinions. If one really wanted an educational experience, it would be better to attend meetings that emphasize reviews of topics or approaches to difficult clinical problems. These often contain research in the form of posters. Most, if not all, scientific meetings include some educational course or the like. This is a rewarding part of the whole affair.

Meetings are also business events. It is an opportunity for the members of the societies to meet and discuss relevant business (regulations, policies, by-laws, statements, guidelines, direction, etc). There is not much more to say about this.

Meetings are also great social events. You can meet old friends and make new ones. I would describe this aspect of a meeting as networking. Networking is very much part of our lexicon and our behaviour. It is part of being a social animal. To network is to interact or engage in informal communication with others for mutual assistance or support (American Heritage Dictionary, 4th edition). I could not have put it more eloquently. Oh, how I do love the clarity of definitions! There is no contempt in my observation. I just put it forward as something obvious. I believe networking is necessary to build alliances and create opportunities. Yet it must be done in a dignified way.

Networking must not be confused with “schmoozing”. To schmooze is to converse casually, especially in order to gain an advantage or make a social connection (American Heritage Dictionary, 4th editions). Again, the lucidity of this definition I cannot surpass. The purpose of networking and schmoozing is similar, but the latter behaviour is more perverse and, certainly, not dignified. This is the disappointing part.*

Meetings can also have pageantry. There is nothing wrong with this. I love history and tradition. It is an expression of our heritage as Thoracic Surgeons. However, academic surgery and its opinions may be overrepresented. The non-academic surgeon should not be forgotten. Yet it is this surgeon that tacitly approves opinions that may not reflect the realities of his or her practice. Again, disappointing.

Meetings also allow us to see what new technology is out there. Companies set up their booths and put on fancy events. It feels to me like the towns that are hastily built around an encamped army and then follow them around during a military campaign. For full disclosure, I have enjoyed a few good meals on their dime.

So why should we attend meetings? For me, it is the ideas that they give me. They are also an opportunity to renew old friendships. If I can network, this is a bonus, but this is not part of my personality. I would prescribe one scientific meeting per year and one educational meeting, as well. If nothing else, they are an opportunity to get away. And guys and gals, bring your wives and husbands.



*If I have been guilty of such behaviour, I apologize, and I deplore myself for it. I have tried very, very hard not to be a participant in such a spectacle.

400 Cases: Quality and Safety

What is the ideal number of cases a cardiac surgeon should do in one year to maintain competency? Estimates range from 100 to 200 cases. It may be argued that doing more cases will translate into better outcomes. However, I will question this assumption and state that there is a threshold above which improved outcomes and safety are compromised. I do not know what this threshold is, but I have chosen an arbitrary number of 400 cases per year as a starting point to put forth my arguments.

My arguments do not apply to the most advanced and specialized centers in the world. These I would consider as quaternary referral institutions. In these centers, the infrastructure exists such that a surgeon may perform 400 cases in one year without the limitations I will outline below. These clinics will have associates, fellows, advanced support staff, and infrastructure that make 400 cases per year for one surgeon safely possible. It also attracts and recruits surgeons and physicians with skill and motivation that are at the upper end of the bell curve. This essay applies to the rest of us.

If a cardiac surgeon performs 400 cases in one year and he/she works 48 weeks in that year (4 weeks off), then they are doing just over 8 cases per week. If an average daily case load is 2 cases per day, then the surgeon is operating 4 days in a week. This leaves one day for an outpatient clinic, continuing medical education, administrative responsibilities, and research (if applicable), assuming a “normal” working day and a 5-day week, excluding on-call duties.

Doing 8 cases per week over time, in my opinion, will lead to chronic physical and mental fatigue. I believe surgeons are trained and encouraged (not overtly) to ignore fatigue and it’s deleterious effects on performance. This “toughness” is rewarded during training by silent approval and the opportunity to do cases. It is later rewarded financially in a fee-for-service environment. This circumstance is further aggravated when on-call duties are taken into account. Some surgeons will operate the next day after having been up the previous night. This acutely fatigued state will aggravate the chronic condition. The negative effects of acute fatigue in the form of sleep deprivation have been clearly documented in medicine. I am unaware of research on the effects of chronic fatigue in medicine, but it is likely to have a similar negative effects. Much like flying an airplane, operating in a cardiac case is a very complex task, where fatigue will compromise the safe conduct of the operation, and potentially lead to an adverse outcome.

Operating is not only a technical act. It is not enough to just know how to operate, but also to know who to operate on, what operation to do, and how to deal with complications as they arise. These are the components of good surgical clinical judgment. Most, if not all, of the decisions about the patient and the operation should be made before one even enters the operating room, including how to deal with potential problems. This can only be done if the surgeon has the time to review thoroughly, completely, and in detail all the available patient data. In addition, the surgeon should have the time to think about the case and develop a plan. The key word here is time. If these intellectual components of surgery are not adhered to with discipline, then quality of care and patient safety are compromised. How can an average surgeon working at an average institution and doing 8 cases per week adequately prepare for a case? I do not believe that they can. To use the flight analogy again, flight planning is as important as the flying.

A surgeon who spends his or her time in the operating room will also not have much time to dedicate to the patients, either pre-operatively or post-operatively. How many patients complain that their surgeon is rushed and does not spend the necessary time to address their concerns? This happens much too often.

Surgeons are not only called upon to operate. They also have other responsibilities related to their profession. These include administrative responsibilities related to their own practice and the institution in which they practice. They also include continuing medical education or maintenance of certification. The latter, in particular, are exceptionally important to the well being of patients. In addition, research and teaching may be components of an academic practice. All of these aspects of a surgical career require time and attention to be done well, or to be done at all. I have directly observed, and experienced as a trainee, the negative effects of a busy surgical practice on research and teaching. I can only surmise the compromises being made to continuing medical education. A professional pilot is expected to have ongoing training and assessments of competency and time is allocated for these endeavours. We owe to our patients and trainees the time to stay current in our discipline. We are also obligated to be academically productive if we are in a University practice.

Most importantly, as human beings, surgeons should also have the time to spend with family and to pursue “hobbies”. This will make us more balanced individuals and in the long run happier people. This can only benefit our patients.

In conclusion, a cardiac surgeon who does 400 cases in one year may be compromising quality of care and patient safety, if they are working in less than a quaternary referral center. What is the ideal number of cases to maintain competency? What is the ideal number of cases to maintain proficiency? These numbers may be an issue for debate. However, it is clear to me that 400 are too many. A surgeon doing this many cases should re-evaluate their practice and perhaps offer younger surgeons more opportunities to attain and maintain competence, while at the same time enhancing the quality of care and safety of patients.

CV ICU: Redux

My last two weblog entries have created quite a hubbub. I will begin by saying that the opinions expressed in my weblog are my own and do not reflect the views of any institution with whom I am or have been associated. However, they are coincident with the views of some and are not exclusively my own. In addition, my writings reflect on my professional experiences over more that a decade. I have trained at different hospitals in Canada and the United States. The essays are a compilation of experience that may or may not reflect on a single place, person, or group.

Critics of my views on the adult CV ICU point out that quality care is being delivered by Intensivists. I do not disagree. My principal point is that quality care can also be provided by an appropriately trained Cardiac Surgeon. I believe that there are particular benefits to having a Cardiac Surgeon be an intensivist to his or her patient and these are outlined in the weblog. My point of view seems irreconcilable with some Intensivist's views, but it remains my opinion.

Interestingly, early on in my career I believed that surgeons could not be intensivists to their patients. This was my Canadian perspective. My views have changed given subsequent experiences in the United States. Rightly or wrongly, I hold Mayo and Cleveland as gold standards of excellence. I believe that trying to emulate what is practiced, thought and promoted at these two institutions has merit.

The Adult CV ICU

I believe that a well and appropriately trained cardiac surgeon is capable of delivering quality care in the adult CV ICU and that he should be primarily responsible for the management of these patients. The cardiac surgeon should not abdicate the care of his patients to the intensivist. The presence of an intensivist may be helpful in the CV ICU, but is not essential. It is erroneous to believe that the only way to acquire the experience and skills to care for CV ICU patients is by becoming and being an intensivist. How has it come about that intensivists at some institutions have gained control of the CV ICU? We have been neglectful and, perhaps, lazy. And now we have to deal with some intensivists that treat us with contempt and who undermine our authority.

I propose that cardiac surgeons understand cardiovascular physiology better that any intensivist. This understanding is essential for the competent, rational, and pathophysiologic-based care of cardiac surgical patients. Cardiac surgeons alter cardiovascular physiology in the operating room and experience it in a way that is more real than any ICU training or experience can provide. Cardiac surgeons also must be, and are, familiar with cardiovascular pharmacology, and see the effects of drug manipulation on the cardiovascular system first hand in the operating room. Of necessity, cardiac surgeons must also be familiar with hemostasis, ventilatory management, and fluid management, because these are relevant considerations in the operating room. These experiences in the OR translate to the CV ICU and the CV ICU is merely an extension of the operating room.

As the "Most Responsible Physician", the cardiac surgeon is the most motivated to ensure a positive outcome for his patient. If a mortality occurs it is the surgeon, not the intensivist, who is held accountable by Colleges, hospitals, and the patient's family. This results in a level of commitment to the patient that is not equaled by anyone else because, at the end of the day, the surgeon must stand alone to explain the outcome of the patient, good or bad. Others have the option of walking away, and many do.

Cardiac surgeons are also doctors. This means that they will have knowledge of the other body systems. This enables them to care of the whole patient in the CV ICU. However, the cardiac surgeon must realize that he is not expert in all body systems and should consult when appropriate. BUT, it is the responsibility of the surgeon to not blindly accept the advice of another consultant. Any new treatment must make pathophysiologic sense and should be applied taking into account the patient's history and overall condition. The surgeon should be willing to question the opinions of other consultants and is entitled to question the advice given.

The training of a cardiac surgeon should include the constant responsibility for, and primary care of, CV ICU patients so that enough experience is gained to care for these patients and the problems that arise. Operating on and caring for cardiac surgical patients in the ICU (and the ward) should be considered equal aspects of cardiac surgery. It is ALL cardiac surgery. This paradigm I experienced at the Mayo Clinic during my fellowship, where I also truly learned to care for CV ICU patients. I found my Canadian training to be deficient in this regard.

Critics of this model of care will state that cardiac surgeons are not able to be in the operating room and care for patients in the ICU at the same time. There are many practical arrangements that can solve this problem, such as hired intensivists that answer to the surgeons, resident coverage 24/7, and other cardiac surgeons being present in the ICU when their colleagues are operating. The primary surgeon remains responsible for the patient and determines the plan of care along with the details of such plan.

The same critics will argue that surgeons cannot be experts in ICU because they have not been trained as intensivists and they cannot keep up with the ICU literature. Training of a CV Surgeon has been addressed above. I would also add that overall training in ICU is not necessary because CV ICU is a niche where a cardiac surgeon, trained as mentioned, can gain enough experience to be competent at it. Much of the ICU literature does not directly apply to the CV ICU patient. What is more, the relevant ICU and CV ICU advances and controversies will likely be published in cardiac sciences literature, which will be followed by the surgeon. Resources, such as Literature Watch in CTSNet and SESATS can help keep the surgeon abreast of the significant advances in intensive care that apply to cardiac patients.

Intensivists will point out that cardiac surgeons are not capable or trained for a multisystem approach to the ICU patient. The reality is that the majority of cardiac patients have 1 or 2 system problems and most of them will have a brief ICU stay, and they can even be managed by a competent nurse practitioner or physician assistant under the direction of a cardiac surgeon. For the minority of patients that develop multisystem problems, the surgeon, by virtue his training and practice in the ICU, should be able to recognize these problems and request consultations in a timely and appropriate manner. What I must stress again is that the surgeon remains in control of the patient's care and should not blindly follow the advice of other consultants or relinquish to others the care of his patient. The surgeon is ultimately responsible and must ultimately decide what he feels is in the best interest of the patient.

Cardiac surgery is not only surgery, but also cardiac intensive care. They are one in the same. I do not agree with the fractionation of the practice. Sometimes we complain about the manner in which intensivists are managing our patients but we are not willing to re-establish our authority in the CV ICU.

Welcome Back to Canada

I am back in Canada. As I get accustomed to the system again, I see how much I have changed and how different things are to me now, after having been to the Mayo and Cleveland Clinics. Things that seemed normal during my residency bother and shock me now:

The lack of professionalism (dress, informality/familiarity, impoliteness, disrespect); nurses calling in "sick"; intensivist that think they are the only ones capable of managing post-op cardiac surgical patients; OR delays and summer slow-downs; provincialism; doctors "treating trials" rather than using clinical judgement; entitlement; surgeons abdicating the care of their patients.

(Just to name a few...)

Although I am glad to be in Canada because of the public health care system, I am loath to accept these improprieties. These things, and many others, are not acceptable to me. But how can I change attitudes? How does one engender excellence? How does one create a culture of service to the patient?

Canadians doctors have much to learn from beyond their borders. Pierre Trudeau was one to look beyond Canada to improve it, and for this he was accused of being arrogant.