Cardiac Surgery Disrupted: The "Dark Side of Innovation" vs. Foresight Failure

I’d bet the majority of the VDM readership (and Medicine at large) would rank cardiac surgery (CS) amongst the top and most-respected specialties — and for good reasons. For many years, heart surgeons have been some of the busiest and best-paid physicians in the country. Their work is often linked to “miraculous cures” and “great saves”…. After all, only the brain can compete with the heart to inspire awe and capture everyone’s imagination. They have been, one might say, “almost alone in that small high place reserved for those chosen to be at the top.”

Now, fast forward to 2007, the November/December issue of VDM, and open to page 175. You will find an informative and well-written article by Ailawadi and Kron that examines the current status of CS: a far cry for sure from the glorious days of yesteryear. This piece on “The Challenges Facing Cardiothoracic Surgeons” is a timely and excellent review of something I suspect — and, in fact, predict — will be studied and talked about for many years to come. The “descent” of cardiac surgery to a zone of challenge, difficulty, and uncertainty about its future is nothing short of an incredible story. Just how did this happen? How did they get from there to here? And here represents a much lower pay, the precipitous decline in the number of bread-and-butter coronary bypasses, a near-total lack of control of patient care, a historically-disastrous non-embrace of new technologies and techniques that have now replaced much of their daily surgical work, the inability to attract enough candidates to their ranks and to fill a majority of residency slot positions… and more. The aforementioned article is a must-read for all those interested in these matters (nearly everyone I would hope); it includes a well-written and complete discussion of what we might call “the anatomy of a disrupted specialty.” I’d simply like to emphasize a few issues that are close to…. well, my heart!

1. The power of disruptive innovative technologies cannot be overemphasized. It was the focus of two Editor’s Corner articles in this journal (2005’s September/October and November/December issues). In truth, the heart has been and is “disruption and innovation-central” for all vascular and endovascular technologies. The enormous impact is now felt everywhere and by everyone.

2. CS failed to recognize the potential of these technologies to overtake their field. And perhaps they were “too busy to pay attention”…. For whatever reason, the failures to embrace and retrain and reinvent (themselves) have resulted — more than anything else — in the reality they now live and confront.

3. The perception and reality of cardiac surgeons as “technicians” (albeit highly skilled, educated, and well paid) have been significant factors as well. Cardiac surgeons are not in control of the patient and do not manage the underlying disease. Unlike vascular surgeons, they seem to have accepted a gradual but unmistakable move in that direction. It was shortsighted and made them vulnerable. Period. While sharing with cardiac surgeons some of the same historic challenges, vascular surgeons retained (throughout) their preeminence as the vascular specialists, with overall responsibility for vascular care — not just procedures. We overcame some of the same issues earlier and perhaps in a more effective way, mainly because of the vascular-practice scenario and the fact that referrals have always been directed to the vascular surgeon, who has been and continues to be regarded as the vascular specialist — not just the one to operate or do a procedure.

4. The significant decrease in reimbursement rates for CS procedures was inevitable, and in line with the rest of the medical and economic landscape in the USA at this time. But it has added another layer of dissatisfaction and challenge that, when put together with the rest, contributes in a measurable way to making CS a less desirable destination as a specialty for new physicians.

5. The sharp decline in interest in CS and the predicted significant shortage of cardiac surgeons over the next 10–20 years is a huge issue for medicine in general and the country as a whole. While advanced less-invasive and even non-surgical technologies will be able to address many of the former “surgical” heart problems, there will continue to be a great number of clinical situations and patients that can only be repaired with “classic” open CS. I don’t see this changing in the foreseeable future.

Are the above-described problems serious? Obviously yes! Are there further challenges down the road? Another yes, particularly as they relate to the development of new technologies and approaches to treatment of structural heart disease — valves in particular. However, one can only hope that cardiac surgeons have learned the lessons of the past 2 decades and will hopefully behave in a more proactive and embracing fashion this time around. Additionally, there are and will be, undoubtedly, new opportunities for CS to shine again, and some of these are discussed in Ailawadi and Kron’s article. And there are the re-training and re-invention scenarios many cardiac surgeons have now embarked upon. Endograft aortic technologies and peripheral endovascular opportunities abound, and no doubt, they will become a major focus for many cardiac surgeons today and tomorrow. Interestingly, such pursuits may well send them into a “collision course” with vascular surgeons who have led such efforts from the beginning…. No one can predict the end result of these interplays, but it will surely be interesting to watch!

So, in the end, was CS' disruption caused by technological innovation or self-inflicted foresight failure? Or, perhaps, an “act of God”.... I'll let the reader decide.