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Eur J Cardiothorac Surg 2004;26:S72-S73
© 2004 Elsevier Science NL
Working Group Report |
Heart Centre, University Hospital, Umea S-90185, Sweden
* Tel.: +46 90 7853676; fax: +46 90 7853601. (Email: torkel.aberg{at}vll.se).
The open Discussion following the ‘If retreat how?’ workshop went on as follows:
Appendix
Conference discussion
Dr A. Kappetein (Rotterdam, Netherlands): I think that everybody agrees with your points to improve cost effectiveness, improve quality, and to take an active leadership role. How do you see or your working group see how we can put this in practice, how can we help the surgeons to improve quality, improve cost effectiveness, take a leadership role? I think it is important that when we leave this room that we have something to work on.
Dr Aberg : Well, most of them are really on a personal level. You can take the initiative both towards cardiologists and towards your own administrators.You can explain that you are willing to help and take the initiative. As to working on cost-effectiveness, there are now methods available. In team building you have to both give and take, and there are also methods available to become the true team builder.
Dr Kappetein : Wouldn't it be an idea to put it in a post graduate education program. Now we know how we can improve cost effectiveness because we heard a talk from Paul Sergeant and Randolph Bolton, but I think that we have to share these ideas more and more. Normally we learn how to put a stitch here and there and which valve to implant, but the post graduate education committee could make a program with a more business-like course for surgeons.
Dr Aberg : The annual meeting is where we try to do as much as possible. So far in the annual meeting we have heavily promoted the Journal because the best material to the Journal comes through the annual meeting. We have expanded the annual meeting to five sessions. We could expand it even more, to six sessions, and treat more of these kinds of subjects... I think it would be a fascinating subject which would attract good papers and good discussion, but that suggestion is for the Council to decide.
Dr J. Pomar (Barcelona, Spain): I fully support what Pieter (Pieter Kappetein) said. I have the impression that at the end, most of the working groups will have the same conclusions, which is good. One of them is how to slowly implement the way of working, the way we are doing today, and to start with residents or in the post graduate time of the specialty, is crucial I think.
We were just talking some hours ago with Pieter that this August we are going to prepare a new curriculum for the school in Bergamo. We have to change. I think we have to get also cardiologists coming to the school in Bergamo to get our residents used to naturally work with them, try to get the new approaches which cardiovascular medicine is going to offer us in the near future. We always complain that cardiologists are always leading these things, and in Spain, the cardiology meeting is no longer called the Spanish Society of Cardiology. It is The Cardiovascular Diseases meeting. So we are all there.
I think we have to actively work proposing programs, and the idea with Pieter was to propose new programs to the Council in September and to have a different perspective. And management, it is an important issue, and many other things I think we can do, research, for instance, and publication, something we often forget. I am quite astonished after what we have seen here: how we are performing better than the stenters, and we still stay here quietly awaiting for something to happen. We don't say anything, and I believe it is important to learn how to transfer to the society what we are really doing and reaching. We have a lot of things to show.
Dr Aberg : May I remind you that the subject of this working group was retreat. It seems that most of us are more interested in going on to the attack (laughter). Please, could we have some views on retreat?
Dr C. Mestres (Barcelona, Spain): I would like you to make very clear for us, especially for me, what does increasing cost effectiveness also by reducing our own costs means? Because to me, I believe we should not downgrade ourselves anymore. I haven't anything against Paul Sergeant or Randy Bolton, but I think going to one-man surgery, if this is the concept, I am afraid that I totally disagree. Because I think, looking at our figures in our place, we squeeze the lemon, it is totally dry, so there is no other way to do that, and everybody's spending is crazy, and then meaning that we will accept that we have to downgrade ourselves, and I think this is the wrong concept. I would like you to make very clear for the audience, and especially for me, because it means that I did not understand anything.
Mr S. Nashef (Cambridge, UK): I would like to speak about retreat. I don't think it is all that bad. If this is true and we are going to lose a substantial number of our coronary surgery to the cardiologists and if we are going to be left with simply the very hard, horrible cases that they don't want to touch, then that means that the volume per cardiac surgeon is going to go down.
Now, at the same time we have heard people describe the pressures on the specialty in the form of the European Working Time Directive and in the form of the inability to use juniors for service and our increasing requirements to do things like audit and research and training. Well, I don't know many cardiac surgeons that have free time on their hands. So if we do retreat and we have more time and it gives us a little bit more space in our working week to address these other areas of our professional work more thoroughly and effectively, it is a good thing.
Tom Treasure was talking yesterday about how nice it was to be able to sit in a multidisciplinary team and discuss every case that comes through the system so that the best treatment is decided on between the disciplines. Well, I don't know many cardiac surgeons that have had the opportunity to do that for the last 10, 15 years. If we go back to that, it may not be a bad thing, and we could see our families more, and, most importantly, do more sailing.
Dr Aberg : If I may answer Carlos’(Carlos Mestres) point, I think both these examples of yesterday were examples of a new thinking which in their hands has been successful. I am not advising that everybody should do exactly that, it is a bit premature. However, this is also evolution. At least, we should have some knowledge about how things can be done if we are really forced to do it in other ways.
But I think that everybody should remember that the cost effectiveness, including the cost part of the equation, is a very important part in the distribution of the health care money from government and from society, and if we can do our things cheaper, it is unethical not to do it.
Dr T. Wahlers (Jena, Germany): Yesterday I made the point concerning an improved information policy of the Society for the public, which means against the cardiologists but as well as for the patients, and since I was a member of a different working group, I think this is a very simple way of interacting with the public, and I don't see it now on the charts, but I want to stimulate to discuss this again.
Dr A. Haverich (Hannover, Germany): If retreat also means attack, and much of the discussion yesterday was related to the drop in cases of coronary surgery, we need a scientific type of council for clinical research within the EACTS. The question is whether we should initiate on the side of our Association a prospective randomized study on triple vessel disease comparing stents versus the best form of surgical treatment that we can offer. Friedrich (Friedrich Mohr) and myself and others discussed that two years ago at our annual meeting. We wanted a study that was not industry-driven, because it is very obvious, and probably also from the outlay of this study now, that the outcome will be positive for the stents. There is no question about it. Marko (Marko Turina) made the comment yesterday that less than 5% of all patients that were suitable for triple vessel treatment, less than 5% were randomized into the older studies. This is now called evidence-based medicine. The conclusions made out of that: a policy that is governing now the money coming from industry into the field, the money coming from the government into the field. So I very much would like to discuss the question whether we should take the very, very difficult task in organizing a multicenter randomized trial on behalf of our Association. We need to get objective criteria and also the follow-up of two years, because we know that the sirolimus stent will be going down the road after 12 months, and this would be one suggestion in forming attack out of retreat.
Dr L. von Segesser (Lausanne, Switzerland): I wanted to take up the point saying that if it is feasible to make it cheaper we should do it. I do not agree at all, because if we would apply this principle, we should not have the meeting in this environment, we should have it outside, even if it is raining, because that is cheaper; we should not eat, well, we shouldn't eat at all, because that is cheaper too. I think that this not a good philosophy. It is good to know that it can be done cheaper, but that doesn't mean that this is the optimal strategy. Sorry.
Dr Aberg : Well, just as a matter of philosophy, Ludwig (Ludwig von Segesser), at least the Swedish parliament took three ethical rules in prioritizing. Cost effectiveness was one of the rules on the point that it is unethical to waste money. So if it can be done cheaper, it is a good thing. Provided, of course, that we have good working conditions and can maintain quality.
Mr B. Keogh (Birmingham, UK): Axel (Axel Haverich), I think your comment about the Association getting involved in clinical studies is, of course, a big discussion which time just doesn't allow us to have now, but I am sure the Council will want to discuss that and will be seeking advice from people who may be interested in taking that forward. So can we just park that one for a second in the interests of time, and we are right on time, Torkel, for Friedrich next, if that is okay.
Footnotes
Presented at the EACTS Symposium for the Future of Cardiac Surgery, Frankfurt, Germany, July 1–2, 2004.
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