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Eur J Cardiothorac Surg 2004;26:465-468
© 2004 Elsevier Science NL
ESTS Presidential address |
Regional Hospital for Lung Diseases, Sokolowskiego str 11, Szczecin-Zdunowo, PL 70-891, Poland
* Tel.: +48-91-462-2070x272; fax: +48-91-462-0494
e-mail: grodzki{at}grodzki.szczecin.pl
Mr Chairman, ladies and gentlemen, dear friends,
It is my great honour to present this lecture on the future of thoracic surgery in Europe to such a distinguished Society. As many of you know, I come from Szczecin, Poland, from quite a large center of thoracic surgery—not the largest nor the most famous one. I think my position as President of this Society proves very well that ESTS offers excellent possibilities for any thoracic surgeon for whom the future of our specialty is precious. ESTS represents highly ranked academic surgeons and pure clinicians, surgeons working in large units and surgeons from small hospitals, surgeons from west, east, north and south.
Thoracic surgery is the oldest of medical specialties. It started in the garden of Eden. Just look at Orvieto's sculpture in Italy of God performing a rib resection. Anaesthetists might claim that someone had to give anesthesia, but I think it was done by one almighty person. Eons later, almost 100 years ago, Ferdinand Sauerbruch from Wroc
aw invented his chamber allowing safe open thoracic surgery. It was an uncertain start to the history of our specialty but definitely we can name it as one of the milestones.
Rapid development of thoracic surgery in the 20th century resulted in a very fruitful period of many (sometimes very important) publications and congresses. But surprisingly, unlike our American colleagues, professional societies at a European level were established relatively late (European Association for Cardiothoracic Surgery in 1986, European Society of Thoracic Surgeons in 1993). From this particular point of view, which concerns scientific societies of European level we had lived on a desert. In the early years of the EACTS cardiac surgery was the predominant specialty represented, with an underrepresentation of thoracic surgery, resulting in a rebellion by thoracic surgeons—the formation of ESTS. I strongly believe that this was necessary even if a difficult event to find our identity in a rapidly changing cardiothoracic world. Fortunately, when both societies matured, people started to look for cooperation rather than competition and has resulted in the promotion of many different joint initiatives run by both societies together. I can enumerate the common Section of Cardiothoracic Surgery within the UEMS, Bergamo School, European Journal of Cardiothoracic Surgery, European Database project, "Structure of general thoracic surgery in Europe" document and the international exchange project. This autumn we will meet in Leipzig for the third joint meeting. The initiatives I have listed are in various stages of completion, but all reflect the will to find solutions rather than problems. The cooperation is defined until 2005 when both societies will analyze it and decide about further initiatives.
When I joined the society the number of members slightly exceeded 100. Right now we have more than 500 members and the number is still growing. Our junior membership is increasing particularly well—it confirms that we are not only the society of old-fashioned professors and heads of departments, but a dynamic body open to young surgeons where there are opportunities for them to serve their society. Shortly after this meeting our representatives are heading to Toronto to the AATS meeting to present ourselves as a leading force in European Thoracic Surgery to our American friends, and we are the leading force in fact. Some of us are members of both the cooperating societies but the difference between the number of thoracic members of EACTS and our membership is ever increasing. We offer a reduced ESTS membership fee to all thoracic members of EACTS and most European EACTS thoracic surgeons are members of both societies. Today, there is no doubt that our society plays the leading role in European thoracic surgery. It makes us proud and grateful to our predecessors who made this society strong and influential from one side, but on the other side it increases pressure and responsibility for our present and future leaders. To consolidate our organization and raise its professional profile we need a full time secretariat. We need leaders with not only a vision, but also the ability to work hard almost on a daily basis. The time when we were semi-amateurs is over and to keep and develop our leadership, we need vision, professionalism and hard work. Last but not the least we need money. To properly manage a modern European Society we need money not only from our members but also from other sources including the medical industry. This should be one of the main short-term goals for the future leaders. I come from Poland—my country was not independent for more than 100 years. Polish people know, may be better than others, how important independence and freedom are for every aspect of our life. The same concerns our society. It is much better to be totally independent than based on strange resources even partially.
I want to emphasize our gratitude to our visionary colleagues from EACTS who supported us financially in difficult times. We deserved this support due to our strong position but despite this we will remember it for ever. Cardiac surgeons are our bigger partners but they also face different problems including the growing role of interventional cardiology or radiology, intraluminal procedures, tissue engineering or genetic interventions. It may happen in future that they will need our financial support and we will respond. Anyone who considers my words as totally theoretical and having an unrealistic vision is kindly asked to recall my remarks in 20 years time.
We have to remember that pneumonologists are usually our close co-workers delivering us surgical cases. Thoracic units that suffer from a lack of patients often result in poor communication with pneumonologists who refer patients to another, sometimes even more remote centers. I do not want to analyze details of cooperation with other specialties in depth but please do not forget about pneumonologists, ICU specialists, radiologists, anesthesiologists, general practitioners and others.
The same issue is present regarding injuries of the chest. They are rarely isolated and often treated by traumatologists, rescue teams, orthopedics or general surgeons. It is easy to criticize their management in retrospect but is not a proper approach. We should rather be ready to join the multidisciplinary team at the time of admission. This is easy if thoracic surgery is located within a large hospital with all the necessary departments but many of us work in specialized hospitals, sometimes transformed from prior TB centers, where there is a problem to find neurosurgeons, orthopedic surgeons or even general surgeons, or ICU specialists. My recommendation from personal experience is to go actively outside one's own hospital and join a multidisciplinary team elsewhere. It requires good local cooperation but it saves many patients’ lives. The society should not underestimate the role of thoracic surgeons in trauma.
I would like to highlight the importance of "Structure of general thoracic surgery in Europe" document. Walter Klepetko, who did the majority of the necessary work regarding this paper, is to be congratulated. As you know, the proposal is based on the improvement in outcome with volume. The GTS structure is a statistical paper but one should be aware that during collection of data we discovered really surprising facts, including a 50% mortality after pneumonectomy in highly civilized countries. The simple explanation of this observation was that fatal surgery was performed in a small unit performing only four pneumonectomies per year. Unfortunately, it still happens—we still observe places with very limited thoracic activity. The society cannot replace the responsible authorities of the region or country but our role as professionals should be at least to minimize probability of such fatal events. There is enough scientific evidence that surgical experience and procedure volume performed by single surgeon influences outcomes. I am deeply convinced that we should promote a model of thoracic units based on minimal requirements described in the above-mentioned document. The European Cardiothoracic Institute of Accreditation (ECTSIA) should be very supportive in our crusade to improve quality of our service. Otherwise, we will face the growing demands of governments and patients without proper facilities. There is a place for smaller units but they should avoid performance of large, complicated procedures. The future belongs rather to centers performing more than 200 thoracotomies per year. We should be aware that accreditation validated by institutes established by cardiothoracic surgeons means not only profits for the positively verified and certified departments but also enormous responsibility for inspectors and the accrediting body.
Coming back for a moment to future models of units and hospitals I would like to mention my stay at Barnes Hospital some years ago. It was a fantastic, but nevertheless a stand-alone hospital. Today, it is a crucial part of a bigger organisation called Barnes Hospital System and as far as I know this change has already brought benefits for the patients and for the economical situation of the health care in Missouri. Duplication of units has been limited; some hospitals were remodelled to fulfill local particular demands regarding, for example, chronic patients, many positions were saved and less people lost their job than before. Some can say that it is an American model but I have to notice that such systems had functioned in Poland several years ago, abandoned at that time but currently under consideration of revitalization. Obviously, it is not a panacea for all problems in health care but at least this idea should be considered in possible future solutions.
As to particular procedures, cardiac and thoracic surgery seems to be totally different except for our common body cavity—the chest. There are few common procedures. This separation is reflected in industry engagement into every specialty. We usually require staplers, sutures and instruments, while cardiac surgery is almost always surrounded by cardiopulmonary bypass, valves, special catheters, octopuses, etc. Several years ago we were nowhere with modern thoracic surgery. The advent of videothoracoscopic surgery as well as gluing, stenting, combined treatment of lung cancer or lung volume reduction surgery and transplantations opened new gates for the industry to go deeper into thoracic surgery. Nevertheless, we are still consuming much less money than our cardiac colleagues. Unfortunately, in some countries salaries offered for thoracic surgeons are lower. We should be aware that some of our members still earn less than 300
per month and it is an enormous financial effort for them to join our meetings or even pay the annual membership fee. Increasing the income of thoracic surgeons is not the main goal of our society but we should remember that prosperity of thoracic surgeons means prosperity for the society and specialty as well. We cannot and should not replace trade unions, but perhaps, it would be worthwhile to establish a committee to monitor vital economical problems of our members including salaries and working time regulations. Thoracic surgeons cannot expect the income of plastic surgeons or gynecologists. We should not be sybarites but even thoracic surgeons should be able to live comfortably.
It is time to establish a committee for trainee members, to give our young colleagues possibilities to become more active within the society. Their generation has a lot of particular topics for discussion: residencies, exams, scientific opportunities, salaries, etc. We not only have to protect and support them but also have to let them speak their own voice. I encourage young men and women to show their initiative.
Returning to common ground shared by cardiac and thoracic surgeons, I suppose that robotic surgery will promote again cooperation between the specialties. It is unrealistic to expect that there will be more than one robot within the cardiac or thoracic unit except in large centers. I am sure the next generation of surgeons will create the subclass of robotic surgery specialists. I would like to remark that we should keep an eye on the changing rules of residency to educate surgeons as broadly as possible. The web-based operation logbook is one of the instruments providing such control and should be promoted by the society. The most advanced robot will not replace the surgeon so I am deeply convinced that our future relies more on humans than robots. This rule is valid not only in medicine but also in other fields as well. The ‘Breitling Orbiter’ would be nothing without our honorary speaker Dr Piccard.
We are not in a position to dictate to governments whether to promote common cardiothoracic units or rather separate cardiac and thoracic units. It looks different in virtually every country. We should promote large busy centers and focus on the idea that chest surgeons should be able to practice both cardiac and thoracic procedures during residency. It is of less importance, which specialty will dominate his or her professional career—everybody should be at least minimally familiar with the other part of chest surgery. It would theoretically increase the social and financial security of a surgeon because it will enable possible transformations from cardiac surgery to thoracic or reverse in case of unexpected independent conditions influencing the professional and private life of our members.
Pulmonary transplantations have been recognized as our absolute top specialty and people who performed it are proud and happy. They are totally right but we have to remember that transplantation is not one surgical procedure but the entire process of harvesting, matching recipients, exchanging lungs and postoperative care and follow up. It is the complex network of events requiring excellent coordination that engages many people and consumes a lot of money. We are all ambitious and would be happy to perform successful transplantation but the learning curve is much sharper and longer in this procedure than in any other in thoracic surgery. The future of transplantation in a small continent like Europe belongs to large centers (one or two per nation) or even to the centers covering areas larger than one country. Usually lung transplantations are performed within normal thoracic unit once a month or less—only a few centers perform more than 20 lung transplantation per year. It should be solved by establishing units dedicated for transplant patients where the entire process from first qualification till long-term follow up is properly managed.
We have achieved a lot, yet not enough, to improve the international education of young thoracic surgeons. The Bergamo, school is to be one of the highlights. Everyone who was there as a student or lecturer is convinced that this school plays a more important role than simple education. In Bergamo, I had a strong feeling that we teach future heads of clinics and departments, who will not be anonymous for each other any more. It will bring us fruits earlier than even we expect. However, this school provides excellent but theoretical education. We should take care of the practical side of training as well. There is a need to promote international exchange based on short-term observational visits and long-term complete training appointments. The latter usually requires the engagement of supporting organizations, special funds, etc. but the option of short (1–2 weeks) visits avoids administrative difficulties and is much easier to arrange. It depends mostly on the good will of the head of the departments and requires minimal effort. Almost every clinic is able to provide cheap accommodation and the visitor is usually able to leave their basic job for a short period even with no reimbursement. On such a basis, I personally visited some of the best centers (living on a very limited private budget). I know how much one can learn from it. Nobody ever refused me a visit and I am still very grateful for the hospitality I experienced during my stays. Such visits are possible and should be promoted in both directions—not only from east to west. Believe me—there are many excellent centers in the former eastern European countries. Perhaps, they are less well equipped, but they can offer reasonable number of cases and lots of cheap and practical solutions. I would like to appeal to all heads of departments present in this room—please open your doors for visitors—it will be good not only for them but also for you. The society will help in this process by providing contacts, organizational support etc.
We are very proud of the European Board exam, now passed by many young colleagues. However, we have to remember that urologists are two steps ahead and have opened such an exam for all European residents. We should follow this lead and establish our exam as an official certificate for qualifying specialists, opening the possibilities to work everywhere in Europe or even farther. There are disadvantages in organizing this exam at the end of the Congress when everybody is tired and in a hurry, although the venue is less important than the high standard of the examination itself. The society should promote high recognition of the Board certificate. We should recruit our best members to the examining body and promote clarity in the process of certification. Cooperation with the UEMS is one of the conditions ‘sine qua non’.
The properly educated young thoracic surgeon should be ready to plan, conduct and conclude a scientific project. Our society is rich in many enthusiastic young colleagues willing to do something for the progress of science. Sometimes, they need wise advice because they do not know exactly what they want to do, but more frequently they suffer from lack of proper laboratories and funds necessary to perform serious scientific work. We have to help them, otherwise they will be limited to publishing papers based on ‘describing the existing clinical world’, retrospective analysis of patients files. The Society has insufficient funds to support scientific projects directly. But we do have members who lead perfectly equipped centers in countries with fewer financial limitations for the promotion of science. I think that prospective, experimental work requiring good animal facilities reasonable funds and a good organizational structure should be concentrated in a few centers. Our role will be to provide access to such centers for all open-minded people regardless of their country of origin. If we want to keep in Europe a strong position in the international scientific field, we have no choice. ESTS recently established a research committee led by an experienced scientist and I hope that this project will bear fruit soon. As to clinical trials, we should navigate towards large multicenter studies. A good example is the European Database project collecting more than 7000 procedures—it gives much better statistical material than even the largest single center files.
Returning to the subject of co-operation between ESTS and EACTS it can be summarized that in the recent past we have learned to live together. Now, we can cooperate without loosing our integrity. Both societies respect their role on mutual terms. I do not consider the idea of a reunion as a must but close cooperation and staying together in the light of multiple external threats and dangers are surely justified. Joint meetings have to be promoted as the best and biggest European annual meeting covering all scientific progress are within our specialties.
As to our society, a lot has been achieved, but there is still a lot more to do. We need to be able to run a full time secretariat, provide stable finances, keep the quality of thoracic part of joint meetings as high as possible, remember that people are our greatest resource. Every single member should know that his or her activity is welcome and plays an important role in the development of the entire society. And, last but not the least, we need the best possible leadership.
I strongly believe that our future will be prosperous and despite dangers along the road, we will be able to achieve goals that were only dreamed of in previous generations. We should be very cautious because the way to the top is always risky. We have to avoid isolation of thoracic surgery from other clinical specialties as well as from friends of thoracic surgery coming from outside—otherwise we will loose our way again. This is a job for us and future generations. As the proverb says, even the longest journey starts with first step. We have just started our journey; we have to use all our abilities to run the European Society of Thoracic Surgeons safely towards thoracic paradise.
Footnotes
Presented at the ESTS Spring Meeting in Zurich, March 25th 2004.
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