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EDITORIAL |
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Gleneagles Medical Centre, Gleneagles Hospital Republic of Singapore |
It would seem like everybody would and should choose to become a cardiac surgeon. However, only a very small minority of surgeons chose to become a cardiac surgeon. In Singapore for example, for the past 30 years, out of more than 5000 doctors, less than half a percent, not more than 18 to 25, have chosen this path. There are very few surgeons in training applying for cardiac surgery traineeship. Although the specialty is a highly satisfying and rewarding one, the road leading to a fully trained cardiac surgeon is tough and grueling. The life of a cardiac surgeon is not a bed of roses. As in Robert Frost's well-known poem: "Two roads divert in a wood and I, I took the one less traveled by." It is a difficult road, full of obstacles, dilemmas, and heartbreaks but the journey is a richly rewarding life experience.
One of the important Hippocratic teachings is "first of all, do no harm." By the very nature of surgery, it has to harm first before it heals. In very few areas of surgery or medicine is the potential for harm as great as that in cardiac surgery. There is a very small margin for error and the resultant harm from a mistake, a lapse of concentration, an error in judgment, can be devastating. For our patients to tell us: "Okay doctor, I will let you saw open my chest bone, stop my heart, and do the operation, knowing that I may die in the process or may never wake up, because you tell me that I would live longer and be healthier," requires tremendous trust. They have faith that we would do our best and do everything right. They think that we would do everything to uphold this trust, that we would choose the right operation and do it to the best of our ability. We in turn have to put the patient above everything else. This is easier said than done. It does not happen every time.
What is the requirement of a cardiac surgeon? Personally, I feel that three ingredients are essential. These are: competence; honesty; and responsibility. Competence in training ourselves to be technically skillful, to be sound in judgment, and to have an urge to continue self-improvement. Honesty to both the patients and to ourselves and responsibility to the patients as well as to society. The most important thing a cardiac surgeon has to do is to decide if a patient needs surgery and what type of surgery is best for that patient. In this, many factors come into consideration, sometimes not in the interest of the patient. The obvious example is minimally invasive direct coronary artery bypass (MIDCAB) surgery. This is an example of the dilemma we face in the selection of a surgical procedure. Surgeons have made their reputations by offering this operation, got mass media attention, and made more money. Hospitals push for this operation to gain patient volume. However, this is one procedure that has had no careful research or established track record. It is a classic example of an operation of doubtful value, full of moral dilemma.
The initial aim of MIDCAB was to reduce the cost of operation by eliminating the heart-lung machine and oxygenator. However, the operation has taken off since 1994 mainly because of its name. "Minimally Invasive" carries a powerful popular image, especially in the press, conjuring the connotation that surgery through a small incision is minimally invasive as well as maximally beneficial to the patients, reducing the hospital stay and the cost of bypass surgery. In reality, surgery through a small incision is technically more difficult. Surgery on a beating heart even with stabilization does not allow the same precise anastomosis as in surgery on an arrested heart. In MIDCAB, choosing the site of the anastomosis depends on finding one that is sufficiently superficial and this site might not be the ideal site for grafting. In order to limit the number of sutures, the arteriotomy tends to be inadequate. In an attempt to find more patients on whom to perform this operation, the surgeon may only graft the left anterior descending and ignore stenoses elsewhere in the right coronary artery as well as the circumflex artery, thus achieving incomplete revascular-ization. To date, there is no controlled trial comparing minimally invasive coronary surgery with the standard operation although it quickly became apparent from the reports that the result of MIDCAB surgery is not comparable to that of conventional surgery. Surgeons simply started doing MIDCAB without bothering to check the results. They reported the clinical outcome and carried out angiograms in a small proportion of patents who survived. Even in the most experienced hands and with stabilization, the problem with patency is at least two to three times higher than standard coronary artery bypass graft surgery. A 90% patency sounds good until you realize that this is much worse than the standard operation. Short and medium-term results of single MIDCAB grafting showed a substantial morbidity, repeat angiography, and reintervention rate. The eventual cost is also likely to be higher. MIDCAB should be more aptly named MADCAB: "Minimal-Access Direct Coronary Artery bypass". This is not something abstract but something real. It affects people's lives. The motto of many surgeons seems to be, "If I don't do it, others will."
The uninformed and gullible public readily accepts smaller incision size, reduced hospital stay, and less cost as equivalent to less invasion and a better surgical result. This is often abetted by cardiac surgeons with their own agenda. There was also much talk about the "learning curve" but we have to realize that there are different meanings of the term "learning curve". The learning curve can be steep and prolonged and the final level reached at the end of the learning curve may not be the same as that achieved by the standard procedure. It is easy to hide behind the term "learning curve" and accept the mortality and complications encountered in the process. We fail to ask, "What happened to those patients who suffered in the process of this learning curve?" Do we not have a responsibility to them or are they merely stepping stones in our attempts to gain something for ourselves? Did these patients give the proper informed consent prior to surgery? I often wonder whether they were given the true picture to enable them to make decisions. Often in the pursuit of being fashionable and keeping up with the competition, we have neglected our responsibility to the very patients who have entrusted their lives in our hands and trusted our judgment and responsibility. It may be better for most of us to leave the exploration of these new and uncertain techniques to some established centers that have good tract records of being honest and scientific. Once there are sufficient correct data and the techniques have been refined and established, the surgeons in clinical practice can then adopt them.
Surgery for high-risk patients is another example of a dilemma in cardiac surgery. This occurs very often in our daily practice. There will always be patients who have reached the end of treatment algorithms but who do not want to die according to the protocol or treatment guidelines. It takes courage or foolhardiness and understanding to take on the burden for which there may be no rewards but only punishment. The high-risk patient has increased probability of death, stroke, long stay in the intensive care unit, and a reduced capacity over the long term. However, on many occasions we discover to our delight that after the operation, the patient has sailed through the postoperative period without any problem and since led a very productive and happy life. Whenever we see such patients at a follow-up visit in the clinic, we have feelings of pride and joy and we are glad that we made the decision to operate instead of allowing him to face certain death within a short period of time without surgery. However, there are also many occasions when the patient does not do well after the operation and we are dejected after failure of the surgery. We wonder whether we were wise to have offered surgery in the first place and whether it was justified to subject the patients to the operation and a long painful intensive care unit stay before finally perishing. These are periods when the intensity and stress and the sense of responsibility and failure can be great. A large part of the tribulations of a cardiac surgeon occurs when we lose a patient. We walk around with our heads bent. There are periods of dejection, depression, of self incrimination, and stress. There is much soul searching and reflection. The feeling is usually not one of shame but of guilt. We wonder if we had really done our best, if we could have done better, we search for our mistakes, wondering if we can avoid doing the same when we next face the same problem. This is how we learn and gain experience, sometimes at the expense of a life, of a person who trusted us. Death is uncommon in cardiac surgery but when it happens, it is dramatic and devastating, not only to the patient's family but to the surgeon and colleagues. Hopefully we learn, although not everyone learns from experience. Sometimes one may have one year's experience repeated 20 times instead of accumulating twenty-years' experience.
Like everything else in cardiac surgery, there is no easy answer and we treat patients one at a time. Each one has a different set of circumstances. We also have to bear in mind our responsibility to society as a whole. It has been estimated that in the year 1994, the treatment cost for the last year of life of the population was three times the amount spent on medical research. But that patient in front of us may want to live just a little longer. How do we refuse such a request? Cardiac surgery is technology-intensive and the cost will go up with developments in technology. Good examples are heart transplant, implantable ventricular assist devices, total artificial heart and extracorporeal membrane oxygenation. This is often a very complicated issue although as surgeons, our first responsibility is to the patient, and we will do our best for the patient, often disregarding the cost that is likely to be involved. It sometimes makes us wonder if a patient has a right to squander a vast amount of the country's resources and to drain surgeons, other doctors, and nurses of much of their energy for days or weeks on end? Or do we have the right to decide that since the chance of success is not high, we should refuse to offer a treatment to the patient even if he wants to live? There is no clear-cut answer. Nobody can tell us what is the cut-off point beyond which we should not attend or offer surgery. We also have to question the relative values. How exactly do we measure the value of relieving angina and what is the value of prolonging a life by 2 years, 5 years, or putting a patient who is at death's door on a left ventricular assist device for days with little hope of recovery? These are things that makes the life of a cardiac surgeon difficult but it also makes the life of a cardiac surgeon interesting.
The ever-changing economic side of medicine will continue to affect cardiac surgery and the way we practice. We are seeing only the beginning of vast changes to come. Things like HMO (Health Maintenance Organiza-tion), increasing prominence of third-party payers like insurance companies, hospitals making deals with com-panies that will limit the services we provide and limit access to surgery. DRG/case-mix (Diagnosis-related group) will increase the pressure to discharge patients earlier and sicker, hospitals will try to link the financial interests of doctors to the hospital via incentive programs and partnerships. Joint ventures and listed companies are trying to buy over our clinical practice and perhaps dictate our clinical service. We need to keep our primary purpose clear, i.e. to serve the patient's interest first and try not to let all these cloud our view in life. The temptation is great when a listed company wants to give us millions of dollars to buy our practice. These temptations are easier to resist when we do not really need the money but they can be very strong, especially if the doctor is financially stressed. We will yield to temptations once in a while. No one is infallible, especially if decisions are made in a hurry without careful thought. But we must rectify our mistakes once we realize them.
We have the obvious obligation to train the next cohort of cardiac surgeons. In this process, there are many stresses and dilemmas again. Training an apprentice to do a procedure to our expected standard of meticulousness and effectiveness is quite a trying and taxing experience. It requires a lot of patience, tact, encouragement, and support. Sometimes we feel like just taking over the case, the patient's welfare and our obligation to the patient are at stake. It is a difficult balance between our duty to the patient and the need to develop confidence in the trainee. Without confidence, he will never develop into a good surgeon. Not all trainees are technically gifted or have a lot of common sense on the operating table. Letting him carry on may shorten the patient's life and shorten the teacher's life. It takes a great deal more skill, emotional toll, and effort to assist than to simply do the operation. Howard Raine, an American Indian Poet, said it very well: "If I can lift you today, you will look back and grab the hands of a thousand more."
What have we achieved by devoting our lives to cardiac surgery? It is hard to quantify exactly. We just do it one step at a time. This poem of Emily Dickinson sums up this aspect well:
If I can stop one heart from breaking,
I shall not live in vain;
If I can ease one life the aching,
Or cool one pain,
Or help one fainting Robin
Unto his nest again,
I shall not live in vain.
In his professional life, the cardiac surgeon tries to place the patient first, all else coming second. Patient responsibility is placed above personal convenience or negotiable family obligation. There is much family sacrifice, making the cardiac surgeon sometimes an unreliable father or husband and a lousy friend. He cannot be absent at important times in the patient's illness. That means that he may not show up for planned family functions, or he may run off halfway through a meal with family and friends. Most of the patients and their families are very grateful. We do encounter once in a while ungrateful patients, threats of medico-legal suits, and complaints to the Medical Council. This can be very taxing but in the final analysis, problems arise only if the patient does not do perfectly well. Much depends on communication and rapport. There will always be one member of a family who does not understand. So long as our conscience is clear and we know that we have done our best, so be it. For the great majority of patients though, their gratitude is deeply rewarding.
The patient has greater appreciation for the cardiac surgeon who has repaired his heart, a lot more than for the colorectal surgeon who has taken out his intestine. Many become loyal friends. We become their confidante. These friendships are the greatest rewards to the cardiac surgeon. At the end of the day, if we ask the cardiac surgeon the classic question, "Would you do it all over again, given the chance to repeat your life?" The surgeon will recall all the hardship, difficult and stressful times, times of trials and tribulations and balance these against the enormous satisfaction he gained from a lifetime of practice in this unique field of surgery, and I think he will say, "Yes."
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