Naunheim Points to Resilience as Key to Survival

Cardiothoracic surgery has been under attack for several decades. Beginning with diagnosis-related groups, the specialty was hit by reduced reimbursement, lower patient volume, and a shrinking workforce. Instead of getting angry, cardiothoracic surgeons got resilient. They worked to influence federal policy, used data to change practice patterns, improved medical guidelines and began to change the face of the specialty, said 2018-2019 STS President Keith S. Naunheim, MD during his Presidential Address on Monday.

Keith S. Nauheim, MD

Keith S. Naunheim, MD

He described how the change began in the mid-1990s when Robert Replogle, MD was STS president and CMS proposed a 45% reimbursement cut to move nurse practitioners, physician assistants, and surgical assistants out of surgical practices and into hospitals.

“He resolved to address this in a strong but constructive fashion,” Dr. Naunheim said. “He restrained his anger, reassessed the situation, and responded to the threat. These days the word for that kind of reaction is resilience, the capacity to recover quickly from difficulties with the ability to spring back or rebound. Resilience means you bend but you do not break. And STS does just that.”

Dr. Naunheim’s address was titled Anger Management 101: Why Am I Angry? Let Me Count the Ways. In retrospect, he said, it should have been called Resilience 101: How Can We Fight Back Against Those SOBs?

For Dr. Replogle, fighting back meant a $1,000 special assessment from each STS member. The Society put together an aggressive, $6 million lobbying campaign in Washington, DC. The campaign resulted in a $1.6 billion increase over 10 years for cardiothoracic surgeons compared to the original proposals, a 26:1 return on investment.

Another hit to the specialty came in the 1990s when balloon dilation and coronary stent implantation were introduced and interventional cardiologists jumped. Percutaneous coronary intervention became the go-to therapy for coronary circulation issues. PCI rates soared; CABG numbers fell.

“The wide application to PCI in the absence of evidence appeared inappropriate and it fell to us, the cardiothoracic surgery community, to affirmatively address this misguided practice,” Dr. Naunheim said.

STS and the American College of Cardiology used data from both organization’s databases to compare long-term outcomes of CABG and PCI. The ASCERT Trial, published in 2012, demonstrated long-term survival benefits for CABG in multiple subgroups.

The Society also led the creation of appropriate use guidelines for PCI in cooperation with ACC, the Society of Cardiovascular Angiography and Interventions, the American Association for Thoracic Surgery, and the American Heart Association. By 2015, the chance of PCI being appropriately used rose from 30% to nearly 50% over 5 years. The inappropriate use of PCI fell by half and CABG volume increased.

“The good guys are winning,” Dr. Naunheim said.

Good women are winning, too, as more women become cardiothoracic surgeons.

The shift reverses trends seen in workforce surveys in 2010 and 2015 showingthe CT workforce in decline even as every other specialty, and the US population, increased. One problem was the decline in surgical volume and jobs, which discouraged medical students from entering the field. The bigger problem, though, was gender. About 0.05% of male medical students were interested in thoracic surgery compared to only 0.01% of female medical students. As medical school enrollment moved from predominately male to a rough balance, training slots went unfilled.

Again, STS leaders collaborated with others to promote and strengthen the specialty. This time it was on the development of TAVR, minimally invasive surgery, and robotics, all attractive, cutting-edge procedures for young surgeons. And the Society worked with Women in Thoracic Surgery to develop and present role models for female medical students and residents.

“We’ve come a long way, but there is still much improvement possible,” Dr. Naunheim said. “Our specialty has been and continues to be under assault from multiple directions and we have to respond on every front. I am convinced that we can and will meet those future challenges and prevail.”