1. I n t e g r i t y - S e r v i c e - E x c e l l e n c e The State of USAF Cardiothoracic and Thoracic Surgery Jerry W. Pratt, MD, FACS, FACC, FCCP Lt Col, USAF MC Chief Consultant to the Surgeon General for Cardiothoracic Surgery McGuire Veterans Affairs Medical Center Richmond VA 81 OL A Surgical Operations Squadron Keesler Medical Center Keesler AFB, MS

2. USAF Cardiothoracic Surgery Sub-Specialty of General Surgery- 45S3C (CTS) Board Certified by American Board of Thoracic Surgery Military Scope of Practice Excludes only transplantation and most congenital heart disease Diseases of Chest Coronary artery disease Heart valves Congenital defects of chest wall Cancer of lung Tumors in chest cavity Coronary artery bypass grafting (CABG) Valve repair/replacement Great vessel repair/replacement Insertion heart failure devices Lung/Tracheal resection Arrhythmia ablation Abnormalities of great vessels Congenital defects of heart Cancer of esophagus Cancer of chest wall Heart and Lung transplantation Esophageal resection Tracheotomies Video-assisted Thoracoscopy Repair chest wall defects Resection tumors in chest/chest wall Insertion of pacemakers/defibrillators

3. USAF Thoracic Surgery Non-Accredited Sub-Specialty of USAF General Surgery- 45S3A (TS) Not Board Certified by American Board of Thoracic Surgery General Surgery & Diseases of Chest and Vascular Disease Cancer of lung Cancer of chest wall Tumors in chest cavity Cancer of esophagus Atherosclerotic disease of major arteries Venous disease Military Scope of Practice General Surgery Lung and Esophageal resection Tracheotomies Video-assisted Thoracoscopy Resection tumors in chest/chest wall Insertion of pacemakers Carotid endarterectomy Abdominal Aortic Aneurysm repair Peripheral artery bypasses Varicose veins Excludes only transplantation and most congenital heart disease } Limited by facility capability and training

4. CQ HEALTHBEAT NEWS June 18, 2007 – 4:53 p.m. Boomers Face Shortage of Heart and Lung Surgeons, Medical Group Says By John Reichard, CQ HealthBeat Editor “A nasty mix of current trends should set off alarm bells in Congress about a coming shortage of heart and lung surgeons… Just as the leading edge of the 78 million baby boomers begins entering Medicare four years from now, many cardiothoracic surgeons will begin retiring, and fewer younger colleagues will emerge from training to take their place…” Cardiothoracic Surgery

5. National Issues Facing Cardiothoracic Surgery Supply Delayed retirement Aging workforce Declining applications to training programs Medical school production (MD, DO) International migration and IMG policies Gender and Generational differences Lifestyle choices Demand Decreasing patient volumes, especially CABG Aging Baby Boomer generation National wealth Public expectations Market Changes Decreasing compensation Cost containment efforts Changing practice patterns/evolution of care delivery Productivity changes (PAs, NPs, IT)/Growth in non- physician clinicians Difficulty among trainees obtaining positions New medical interventions

6. Active Thoracic Surgeons 1990 -2004 4,200 4,300 4,400 4,500 4,600 4,700 4,800 4,900 5,000 5,100 5,200 1990 1991 1992 1993 1994 1995 1996 1997199819992000 2001200220032004 2005 Source: AMA Masterfile, 2006. Includes Physicians Self-Designating asCardiovascular Surgery, Cardiothoracic Surgery, and Thoracic Surgery Cardiothoracic Surgery

7. Age/Sex Distribution of CT Surgeons Over Half of CT Surgeons are Over Age 55 6 62 66 25 21 18 1,024 1,565 1,423 612 780 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 <3535-4445-5455-64 65-69 70>= Female Male Cardiothoracic Surgery

8. Source: AAMC Survey of Physicians Under 50 Cardiothoracic Surgeon Job Satisfaction 0 5 10 15 20 25 30 35 40 45 Career in Medicine Specialty Work Schedule Job/Position Income CT Other Cardiothoracic Surgery Percent Somewhat or Very Satisfied

10. Cardiothoracic Surgery Thoracic Surgery Match Results Match YearNumber of Programs Positions OfferedNumber of Matches Percent Filled Number of Applicants Programs Ranked Per Applicant MeanMedian 19979513813396%17576 19989513712893%15688 19999513912892%15688 20009414113596%148na 20019414413191%14988 20029314412385%14588 20039214113294%16198 20049213812188%13489 20059113910072%10499 2006901268467%9197 2007 92 NRMP Data Bank 1308767%103

11. Cardiothoracic Surgery General Surgery Residency No longer required to rotate on cardiac surgery service Still required to obtain minimum number of major thoracic surgery cases Elective rotation can be performed at chief level ACGME, 2008

12. Cardiothoracic Surgery

13. Student satisfaction impacted most by: Experience in OR, especially direct interaction with attendings Quality of HS teaching

14. Cardiothoracic Surgery Surveyed 3 rd year students before/after clerkship Positive experiences on the surgery rotation doubled the number of students entering surgery Scrubbed/involved in cases Resident and faculty interaction

15. Cardiothoracic Surgery

16. Compared students’ ratings of surgery rotation before/after DHR Negative comments about residents as supervisors, teachers, and teaching activities increased Positive comments about bedside teaching decreased Ann Surg 2005; 242: 548-55.

17. US Population > Age 65 Will Double by 2030 United States Population Projection Cardiothoracic Surgery US Population Doubles by 2030

18. AAMC, 1980, 1990, 2000 & 2003 Center for Workforce Studies Utilization of resources increases with age and time Health Care Resource Use Cardiothoracic Surgery

19. 0 500 1,000 1,500 2,000 2,500 3,000 3,500 <11-45-910-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485+ Male Female Cancer Incidence per 100,000 by Age

20. 1994—2004, AHRQ HCUP Data -15.0% -10.0%-5.0%0.0%5.0%10.0%15.0% 20.0% 25.0%30.0%35.0% Pulmonary resection Other thoracic Valve Other cardiac Aortic CABG Percent Change Non-CABG procedures are increasing Cardiothoracic Surgery

21. OECD data CABG per 100,000 (2003) 0 20 40 60 80 100 120 140 160 180 Australia Austria Canada Denmark Finland Germany Hungary Iceland Ireland Italy Luxembourg Netherlands New Norway Sweden Switzerland UKUS US CABG Rate Is 2X to 3X Other Developed Countries Cardiothoracic Surgery

22. “Is There an Existing Surplus of CT Surgeons?” Year CT Discharges CT Surgeons Procedures per Surgeon 1993 754,8314,581 165 1997 860,8924,849 178 2004 773,0844,734 163 Sources: AMA Master file, HCUP Nationwide Inpatient Sample (NIS) and AHRQ Cardiothoracic Surgery

23. 1995 1999 2002 2005 Single-Surgeon’s Case Distribution 1995-2005 Cardiothoracic Surgery

24. Cardiothoracic Surgeon Demand Projections - 1,000 2,000 3,000 4,000 5,000 6,000 7,000 20052010201520202025 Year Thoracic Surgeons Status Quo No CABG, +20% non-CABG CABG Eliminated Cardiothoracic Surgery

25. Supply and Demand Projections for CT Surgeons SUPPLY DEMAND 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 2006 2007 2008 2009 2010 2011 2012 2013 20142015 2016 20172018 2019 2020 2021 2022 2023 2024 2025 Year Cardiothoracic Surgery

26. Private sector benchmarks Provider to population ratio 1:100,000 AFMS 1:37,350 (2005) Medicare population 57% AFMS 80% (2005) Outcomes Inverse relationship between surgeon and institution cardiac surgery volume levels and mortality rates National Average CABG mortality ~ 3% Quality Assurance and Performance Data STS (Society of Thoracic Surgeons) Database CICSP (Continuous Improvement in Cardiac Surgery Program) Veterans Affairs Cardiac Surgery Board

27. Cardiothoracic Surgery Hospital Volumes (Quintiles) Goodney et al. Circulation 107 (3): 384, 2002 Medicare Averages for Cardiac Surgery

28. Cardiothoracic Surgery ACC/AHA GUIDELINES for Percutaneous Coronary Intervention Role of On-Site Cardiac Surgical Backup CLASS I 1. Elective PCI should be performed by operators with acceptable annual volumes (75 procedures) at high-volume centers (>400 procedures annually) that provide immediately available on-site emergency cardiac surgical services. (Level of Evidence: B) 2. primary PCI for patients with STEMI should be performed in facilities with on- site cardiac surgery. (Level of Evidence: B) CLASS III Elective PCI should not be performed at institutions that do not provide on-site cardiac surgery. (Level of Evidence: C) Recommendation: Elective PCI should not be performed in facilities without on-site cardiac surgery. Convenience should not replace safety and efficacy. ACC/AHA/SCAI 2005 Update

29. Cardiothoracic Surgery ACC/AHA GUIDELINES for Percutaneous Coronary Intervention Primary PCI for STEMI Without On-Site Cardiac Surgery CLASS IIb 1. Primary PCI for patients with STEMI might be considered in hospitals without on-site cardiac surgery, provided appropriate planning for program development, including experienced operators(75 PCIs, 11 for STEMI), experienced catheterization team on call 24/7, well equipped lab to include IABP capability, and proven plan for rapid transport with appropriate hemodynamic support capability for transfer to nearby hospital with cardiac surgery. (Level of Evidence: B) CLASS III 1. Primary PCI should not be performed in hospitals without on-site cardiac surgery and without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capability for transfer. (Level of Evidence: C) ACC/AHA/SCAI 2005 Update

30. Cardiothoracic Surgery Cardiothoracic Surgery is totally dependent on medical subspecialty care for patient referrals Wide spectrum of multidisciplinary care for patients Cardiology, Pulmonology, Emergency Medicine, Nephrology, Neurology, Vascular Surgery, Pathology, Blood Bank/Lab, Radiology, Nuclear Medicine, Radiation Oncology, Hematology/Oncology, (Cardiac) Anesthesia, Endocrinology, Cardiopulmonary Rehab, Respiratory Therapy, Physical Therapy, Occupational Therapy, Nutritional Medicine, Wellness/Smoking Cessation, Dentistry, Critical Care Nursing Team Concept Cardiology, Pulmonology, Vascular Surgery, Cardiac Anesthesiology- ALL OF THE ABOVE Physician Assistants, Perfusionists, Nurse Coordinator/Practitioner, Clinical Technicians, Administrative Technicians (Critical Care, Operating Room, Ward) Nurses/Technicians

31. Cardiothoracic Surgery Summary and Implications Shortfall of CT surgeons may be a great as 3000 by 2025 Shortage of CT surgeons persists even if CABG eliminated High demand scenarios require increased trainees Fewer medical students and residents interested in CT surgery Increasing population of Medicare-eligible DoD beneficiaries National trends DO affect AFMS in parallel manner What Should Be Done with Air Force Cardiothoracic Surgeons?

32. AIR FORCE TIMES January 14, 2008 Medical Emergency: Air Force facilities, programs need a shot in the arm. By David R. Welling, M.D., Col. USAF (Retired) “..… Air Force medicine is fast evaporating, gone to Tricare or the Base Closure and Realignment Commission. How did that happen? Who is responsible?…” Air Force Surgery

33. USAF Cardiothoracic Surgery “ Changes in military systems come about only through the pressure of public opinion or disaster in war.” General Billy Mitchell p. 62, James Bradley, Flyboys, 2003.

34. DoD Cardiothoracic Surgery USN USA JOINT in 2011 USAF in VAs C CURRENTLY NO STAND ALONE AF CT PROGRAM

35. USAF Cardiothoracic Surgery CTS MANNING 2008 3 San Antonio Military Medical Center 1 McGuire VA Medical Center, Richmond VA 1 Durham VA Medical Center, Durham, NC 1 Completing Fellowship June 08 6 TOTAL 4 Current Billeted Positions 5 Projected until 2012 4 Projected until 2016 Surplus of Cardiothoracic Surgeons Deployment, GME, Manning Requirement for 2 per site } Assigned to Keesler Long Term Commitment =

36. USAF Cardiothoracic Surgery CTS CURRENCY SAMMC: 150-180 Cardiac Cases 3 USA and 3 USAF assigned to SAMMC Divided among 5 Military CT Surgeons (Average 40 cases annually) UTHSCSA- 80 Cases/year for one AF CT Surgeon American Board Thoracic Surgery Requires 100 surgical cases per year Recommends 50 cardiac cases per year Quality Assurance measures and compliance required Peer recommendations CME Self-Education Self Assessment in Thoracic Surgery (SESATS) every 5 years Recertification every 10 years- No General Surgery Re-certification required

37. USAF Thoracic Surgery TS MANNING 2008 6 Current Billeted Positions 5 Projected in 2008 4 Projected in 2009 3 Projected until 2012 WP, Eglin, Keesler

38. USAF Thoracic Surgery TS CURRENCY No requirements for currency RSVP 20 major and 20 minor Thoracic surgical cases over 20 months American Board Thoracic Surgery N/A American Board of Surgery Vascular Surgery Board N/A

39. USAF Cardiothoracic Surgery CTS/TS READINESS FFGKT UTC Thoracic Surgeon Augmentee Thoracic, Trauma, and Vascular Surgical capabilities 4 month AEF rotation to 332 EMDG, Balad AB, Iraq No Afghanistan rotation 45S3C assumes 45S3A Thoracic Surgeon rotations in 2008 Readiness Skills Verification Program 20 major and 20 minor Thoracic surgical cases over 20 months No Cardiac surgery requirement ATLS

40. USAF Cardiothoracic Surgery Surgery Questionnaire (2003) Not Busy Enough Clinically Negative Issues Lack of Clinical Material/Skills Retention Lack of Administrative Support Lack of Value Attributed to Surgery Inadequate Compensation Positives Issues Colleagues, Patients Lifestyle Serving Country/Patriotism Travel/Cultural Opportunities Shielded from Office/Malpractice/Billing GME/Medical Center Participation Deployments

41. USAF Cardiothoracic Surgery New Cardiothoracic Surgery Program Goals Maximize beneficiary populations –Joint DoD/VA Program »CANNOT SURVIVE AS STAND ALONE DoD PROGRAM »Limited Impact to Existing VA Programs –Easy access to care –Commitment to Medicare-eligible patients (TriCare Plus & TriCare for Life) –Academic/University Affiliation Center of Excellence in Cardiovascular and Thoracic Medicine Guidelines for Standards VA Cardiac Surgery Board guidance/control Quality Assurance and Outcomes- Enrollment in STS and/or CICSP Database Minimum Cardiac Surgery Case Volume- 150 annually –3-year Probationary Time Period –Terminate Non-Viable Program Control of Staffing for Physicians/Support

42. USAF Cardiothoracic Surgery New Cardiothoracic Surgery Program Pre-Requisites Establish MOUs/Sharing Agreements –Maintain surgical currency in transition period –Limit impact to program during deployment/military duties –Long term relationships –Academia –Support staff training programs –Establish self-referral patterns/patient flow –Financial considerations Establish formal VA commitments –Patients/Staffing/Financial Considerations Augment Medical Subspecialists and Support Staff –Initiate referrals/Confirm surgical volume estimates Facilities Modification/Upgrades/Modernization/Completion Establish TriCare review process and RoR (Right of Refusal) for all regional cardiovascular and thoracic services Change current mentality regarding Medicare-eligible patients

43. USAF Cardiothoracic Surgery PRO Current facility adequate On-site Simulation training center On-site wellness center Clinical investigations facility VA clinic in Sacramento AF staffing/funding Multi-specialty care support University California at Davis Medical Center/training/trauma center/residents Family Practice/General Surgery/Radiology/Nurse Anesthetist/Dental GME VA/DoD population AF CTS program AF-VA relationship AF-UC Davis relationship Needs, facility, business analysis done CON Modernization of current facility No DoD outpatient clinic in Sacramento AF staffing/funding Limited multi-specialty care No interventional cardiology on-site MOUs/sharing agreements AF CTS program VISN 21 referral pattern, impact to San Francisco/Palo Alto Want VA Cardiac Surgery Board oversight Downsizing of DGMC Access to care at DGMC Non-viable Vascular Surgery program TRAVIS AFB

44. USAF Cardiothoracic Surgery FUTURE VISION=REALITY “Re-build” DGMC into the full service “Air Force” Medical Center Create new AF (DoD)-based cardiac surgery program in 2010 Requires shared VA-DoD/Medicare-eligible beneficiaries Guidance of VA Cardiac Surgery Board Establish MOUs/sharing agreements with UC Davis & VHA in 2008 Begin modernization of facility by 2009 Begin augmenting medical subspecialties/support staff in 2008 TRAVIS AFB

45. USAF Cardiothoracic Surgery PRO New VA facility Surrounding VA clinics VA staffing/funding University Medical Center/ residents/training/trauma center Touro University Medical school/students/PAs Family Practice GME CTS private practice relationship VA/DoD population VA CTS program AF-VA relationship CON Current facility inadequate New VA facility not until 2011/2012 CTS private practice No university/academic CTS programs Multiple MOUs/sharing agreements with multiple parties VA CTS program VISN 22 referral pattern Needs VA Cardiac Surgery Board approval Minimal multi-specialty care available No interventional cardiology on-site VA-DoD currently segregated/ redundant No needs, facility, business analysis NELLIS AFB

46. USAF Cardiothoracic Surgery FUTURE VISION? Create new (2) non-segregated VA-DoD Medical Center(s) in Las Vegas by 2012 Create new VA-based cardiac surgery program VA-DoD/Medicare-eligible beneficiaries Guidance/control of VA Cardiac Surgery Board Supplemental AF staffing in surgical/medical specialties with VA Establish MOUs/sharing agreements by 2010 Begin augmenting medical subspecialties/support staff in 2010 Remove/relocate AF CTS components from SAMMC NELLIS AFB

47. USAF Thoracic and Cardiothoracic Surgery Integrated Forecast Board Cardiothoracic Surgery Add 2 fellowship positions to increase authorizations to 6 by 2013 Ideally 3 CT surgeons per 2 sites Thoracic Surgery Attempt to fill 1 year non-accredited position for 2009 ? Biloxi VA ? University CA San Francisco- allows for guidance by DGMC CTS Create accredited Thoracic Surgeons in 2 year fellowships utilizing Thoracic Tract of ABTS Requested 2 positions for 2010 start

48. USAF Cardiothoracic Surgery RECOMMENDATIONS Maintain Cardiothoracic Surgery as surgical subspecialty in AFMS Train ACGME accredited Thoracic Surgeons Position Thoracic surgeons at sites where they maintain thoracic surgical currency Restructuring of David Grant Medical Center, creating joint DoD/VA Cardiothoracic Surgery services, by 2010 Plan for providing subspecialty services in conjunction with VHA, to include joint Cardiothoracic Surgery, at the new Las Vegas VA Medical Center by 2012 Continue current placement of Air Force CT surgeons in VA Medical Centers until formal commitment(s) to new program(s) and transition period(s) begin Consider transitioning/redeploying AF Cardiothoracic Surgery assets from SAMMC to new program(s)

49. USAF Cardiothoracic Surgery CONCLUSIONS We are at that point of “disaster” whereby it is time to “change” the Air Force and DoD health care systems. We must re-build, re-evaluate, refurbish and renew Air Force Medical Centers and military medicine. We must re-design and revise our medical systems to function efficiently. We must re-connect with the Veterans Health Administration to provide comprehensive joint DoD/VA multi-specialty care services. We must re-capture the leakage of medical care to the network. We must revamp the TriCare HMO system. We must re-commit medical care to our growing Medicare- eligible beneficiary population in our medical centers. We must repair our image to our beneficiaries and staff.

50. USAF Cardiothoracic Surgery CONCLUSION Beginning of an era of large supply-demand mismatch of cardiothoracic surgeons, nationwide Air Force CT surgeons with insufficient workload Responsibility to reposition (subspecialty) resources to sites where they can make the most significant impact