Bavaria Urges Out-of-the-Box Thinking

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Joseph E. Bavaria, MD: ‘Innovation has become absolutely critical to the survival of our specialty.’

The fine line between delivering quality treatment and embracing innovation may sometimes make cardiothoracic surgeons feel trapped between conflicting goals. In his Presidential Address Monday, Joseph E. Bavaria, MD challenged that convention.

“What if these two fundamentally important obligations, which go so far as to almost define us, are at odds with each other? If they are in fact colliding, then this is a challenge that we must sort out,” he said.

Cardiothoracic surgeons have overcome similar challenges, such as when they refined training programs, adapted to the technological advances of minimally invasive surgery and transcatheter aortic valve replacement, and supported the growth of subspecialties, including thoracic aortic surgery.

“However, one of cardiothoracic surgery’s biggest and most pressing challenges, and indeed a challenge for the entirety of medicine at this point, is the colliding imperative of innovation and an unwavering commitment to quality,” Dr. Bavaria said.

There is even conflict within innovation and quality. Is it better to always be an innovator, adopting promising technology and navigating a difficult learning curve, or to wait for guidelines on that new technology?

“Innovation has become absolutely critical to the survival of our specialty. We must experiment. We must continually adapt. And I know we are up to the challenge,” Dr. Bavaria said.

Cardiothoracic surgery should work to build a culture of innovation by emphasizing democracy and freedom of inquiry within the specialty.

“Enlightened leadership is necessary in order to achieve a culture of innovation. Enlightened leadership requires at least some deviation from the principles of autocracy,” Dr. Bavaria said.

History shows that great progress comes with the growth of liberty among the commoners, not the leaders, he said.

“Is a culture that requires rigid conformity capable of significant innovation by its people?” Dr. Bavaria asked. “Liberated surgeons can be ingenious. So innovation—or importantly, early adoption of innovation—is an imperative.”

Moving to the issue of quality, STS has been a leader in this area with its long-established collection of raw outcomes metrics, risk-adjusted metrics, and updated risk-adjustment models.

“The STS National Database has had a long evolution toward improving its ability to generate meaningful measures that can discriminate and point to a ‘quality’ program,” Dr. Bavaria said, but he added that using complex data to create simple grades is a challenge. “Are the risk-adjustment models strong enough? Do they penalize or reward larger, tertiary institutions doing more complex cases?”

There is struggle within the conflict to measure quality that requires new adjustments, he said.

“We need simplicity in outcomes reporting, but the reality is that outcomes reporting is, indeed, very complicated and requires a certain sophistication for accuracy,” Dr. Bavaria said, while acknowledging the importance of public reporting.

“We will have to walk the fine line between the public’s increasing insistence on the right to know versus our duty and responsibility toward our cardiothoracic surgical tribe, as we cannot allow good surgeons and good programs to be misrepresented and perish in the public square,” he said, adding that poor outcomes can lead to risk aversion.

Dr. Bavaria suggested exploring the concept of patient-centered and patient-reported outcomes.

“The collision is not necessary if we keep the patient in mind. In this model, we convert the collision into a merger. The patients and their families become deeply involved with the decision making,” he said. “By discussing all the treatment options, with full consent, including high-risk and alternative options, we can affect a patient-centered outcome, and risk aversion can be moderated.

“Incorporation of patient-reported outcomes or even more advanced patient-centered outcomes into our quality metrics will be difficult. It will require a better understanding of this new concept, as well as proper execution. However, we must move in a direction that manages the conflict between quality outcomes and continued innovation.”

Dr. Bavaria concluded his address by urging cardiothoracic surgeons to continue embracing innovation and quality.

“I ask you to search for solutions for yourselves and your programs so that these two important imperatives don’t collide. This requires out-of-the-box thinking. But remember, we make the boxes. We construct those boxes that constrain our thinking,” he said.

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