The American public seems to consider cancer and cardiovascular disease in diametrically opposing ways. Cancer evokes the threat of relentless, painful suffering and whatever medical science can do to delay the judgement day is appreciated. Therapeutic regimens may involve disfiguring operations, prolonged toxic irradiation and chemotherapeutic agents that may be beneficial if they do not kill you first.
Response to treatment of limited incidence and duration are accepted and deemed beneficial. Recurrence after therapy is often attributed to innate tumor aggressiveness. The cancerous process is beyond a patient’s control. Chromosomal aberrations and environmental toxins trigger carcinogenesis in undeserving people. Even tobacco abuse is blamed on unscrupulous tobacco companies, passive smoke exposure or faulty building insulation. There are few data bases comparing survival and complications for specific treatments between individual hospitals or practitioners.
Compare this regard for the vagaries of cancer incidence and treatment with the strict scrutiny of the cardiac surgeon. Despite decades of self abuse, patients expect surgical treatment of coronary artery disease to be painless, not deforming, mostly risk-free and curative. Untoward events are implicitly due to incompetence and subject to litigation. Patients not taking responsibility for modifying their lifestyle to retard disease progression is accepted as human frailty. No medical practice is subjected to the public scrutiny as cardiac surgery. Hospitals and surgeons have their reputations besmirched or praised in newspapers or magazines for supposed poor results with little consideration as to whether different patient populations are in fact comparable. In summary, the public has little tolerance for an imperfect result following open heart surgery.
Why do cardiac surgeons have to answer to a more demanding grading system? Maybe they have themselves to blame. Holding another person’s heart in your hand confers an aura of omnipotence. This high profile is accentuated by the facts that the practice is technologically intense, requires a cadre of skilled personnel and it is relatively new with rapid improvements in technique and results. All of which have occurred within the memory span of their patient population.
With this background, previously richly compensated people may have reinforced the unrealistic expectations of the public and are now facing the consequences. The current trend of decreasing surgical volume, lower reimbursement and more stringent operative criteria have chastened cardiac surgeons. Hopefully, their patients’ tolerance and expectations will be appropriately modified, not too expect inferior care, just more realistic outcomes and also understand the importance of taking control of their own risk factors.
Norman Silverman is a cardiothoracic surgeon and founder of Heart Surgery Guide.
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