I am writing this blog to discuss ideas concerning my beloved job and hobby: the field of cardiothoracic surgery. I hope my passion for the field of CT surgery comes through in the desire to share my ideas. The target for this blog are potential patients, past patients, interested public and anybody that is intrigued about the observation that adopting innovations seems to be more difficult in cardiac surgery as compared to other surgical fields. I have spent the bulk of my career trying to innovate in this most conservative field in medicine. These experiences have sometimes been successful (more often not) but have always given me unique and sometimes painful insights into the struggles that cardiac surgeons face when trying to adopt innovations that lead to less invasive surgery.
As for an introduction, I was born in Dallas, Texas in the 60’s as the second oldest of a family of 4 overachievers. Each of my siblings were high school valedictorians (except me) and all well accomplished collegiate athletes. After graduating from the University of Texas, I managed to get the support of UT Alumnus Dr. Denton Cooley in my application to Johns Hopkins Medical School. Even with the support of this distinguished (and financially generous) Hopkins alum, I was still the last one admitted off the waiting list only 2 days prior to the first day of class. The admission director’s stated concern was my academic preparation (i.e. jock from a state school). Nevertheless, I ended up graduating 4 years later ranked in the top 5 out of 120 of what US News considered the top medical school in the nation. This early success gave me the confidence downstream to tackle the toughest challenges that I could find – scoring in the top 1% in my boards for medical, surgical and subspecialty exams, receiving high marks from some of the most prestigious residency programs (UCSF, Stanford, U Pitt), and being awarded a prestigious NIH RO1 grant as a junior attending CT surgeon at U Maryland.
It was in my third year as an Attending at U Maryland that I first became interested in robotic heart surgery. It may seem obvious to the lay public that a surgeon should want to avoid the traditional sternum splitting procedure (i.e. sawing open the chest). This is particularly true if the same exact procedure can be done without compromising the long term surgical result. All physicians innately recognize that patients fear surgical incisions that are morbid and take a long time to heal. An incision that requires a saw to create is clearly morbid. Despite the logic of these obvious facts, 99% of heart surgeons in the US only use open chest incisions to operate on patients referred to them. Moreover, there currently exists no ethical or legal imperative for a surgeon that only operates using open techniques to disclose that there is a less invasive alternative to the patient or their referring provider. This remains true even when the referred patients would be appropriate candidates in the hands of other surgeons experienced with the less invasive techniques.
It was clear from the beginning that this procedure was an even tougher challenge than anything I had faced during training or in my academic career. I remember very clearly how disorienting my first several cases were. It was surreal to experience operating on a patient robotically through a video console without being able to touch the actual surgical tissues. This amounts to a dramatic shift in the way heart surgery is performed. My mentors always stressed the importance of directly feeling/palpating the heart and vascular tissues as an integral part of excellent surgical technique. The stark contrast from open surgery creates a major distraction in the mind of the heart surgeon who is a robotic novice, increasing the risk of errors of technique, judgment or communication. Several of my first cases during the so called “learning curve” phase had unexpected complications, greater rates of bleeding and prolonged times required to be in the operating room. My mentor, Dr. Bartley Griffith, was very supportive and convinced the team to persist in the development of the nascent robotic program. We did and the program ultimately was a success with a summary of the results of our first 100 cases at UMaryland published in a highly rated surgical journal (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2649713/). To date, I have continued to achieve success in robotic heart surgery with an experience from 5 different programs that now exceeds 900 cases.
Another thing that intrigued me right away about robotic cardiac surgery was its perception by others in the field with suspicion and controversy. At the time I started doing robotic cases, almost every other surgical specialty had adopted less invasive techniques. Patients referred for cardiac surgery were no different in their desire for these techniques. It seemed self-evident based on the experiences of other fields that a period of learning was going to be required, perhaps longer in duration at some programs as compared to others.
All of our initial patients were fully informed of the potential risks associated with our inexperience. Our efforts to learn from experience and drive continuous quality improvements for this procedure during this timeframe were tireless. Yet there was a growing chorus of naysaying cardiac surgeons that either had never tried robotic surgery or underwent robotic training and later dropped the method. The existence of this type of group of “late laggards” is predictable based on well accepted theories about how any innovation is adopted. The difference in the case of robotic heart surgery is the power this group has to block its wide-spread adoption. As a rebel at heart, I actually enjoyed the attention (albeit negative) that I drew from colleagues when I was pursuing the robotic program. I learned from subsequent experiences that this is not a good (or helpful) thing to enjoy.
I look forward to sharing more in-depth details on many of the topics introduced above. More importantly, I am hoping to receive feedback from those reading this blog about what you think about my ideas. If you are a patient that has been referred for surgery, I hope these comments help make you more comfortable with me as a potential surgeon for your case. If you are a past patient, I hope you use this blog to stay in touch and invite you to tell me where I’m off base compared to your experiences. I judge the success of this blog based on overall participation.