1. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Current status of young cardiac surgeons in Japan Kan Nawata Naoto Miyagi, Hiroo Takayama, Shin Takabayashi JAYCS: Japanese Association of Young Cardiac Surgeons

2. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Cardiovascular Surgery in Japan Annual report by the Japanese Association for Thoracic Surgery Calendar Year Number of Cases

3. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco The number of Japanese CV surgeons the Japanese Board of Cardiovascular SurgeryCertificated by the Japanese Board of Cardiovascular Surgery (since Jan. 2002) 316 Main Hospitals (>100 cases per year) 127 Satellite Hospitals (>50 cases per year) Approx. 2,000 certificated cardiovascular surgeons (including vascular surgeons) + More than 1,000 uncertified CV surgeons !

4. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Why so many CV surgeons in Japan? No regulation about the whole number of CV surgeons in Japan Many hospitals where cardiac and aortic surgeries are performed –No regulation regarding opening a new cardiovascular surgery program in Japan –Better accessibility from the patients’ viewpoint Fewer co-medical professionals –No Physician Assistants –Postoperative management by young CV surgeons –Endless miscellaneous duties

5. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Unsolved issues in Japan #1: Regionalizaton Because of no regulation regarding opening a new cardiovascular surgery program in Japan, non-high quality low volume programs exist in large numbers 5 Hospital annual CABG volume mortality rate

6. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco 6 percent Surgeons have routine miscellaneous duties47.3 % Surgeons routinely have over 32-hour labor96.1 % No preferential pay for cardiac surgeons94.6 % ↓ These conditions are unfavorable not only for cardiac surgeons but also for patients who receive medical care Status of working conditions regarding Japanese CV surgeons (by questionnaires) Unsolved issues in Japan #2: Status of Labor

7. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Non-high quality low volume programs in some hospitals Consultant surgeons who are still eager to operate by themselves Long training at the bottom of the heap Relatively low income Uncertainty over their career path A considerable number of Japanese CV surgeons go abroad for more clinical experience. Is it acceptable as one of the developed countries? Young CV surgeons in Japan confront

8. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco On the other hand,

9. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco How are the operative outcomes? Good operative outcomes for the smaller number of cases experienced per year JTCVS 2008;135:1306-12 Japan SCORE

10. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco 10 No. of Pts178065309419947998586227749462673411493117215 No. of Hsp87105946855282921101330 Unadjusted 30-day mortality rates by CABG procedural volume in Japan In Japan, all categories over 41 CABG procedures per year were 30-day mortality rates under 2.0% Number of Isolated CABG Admissions

11. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco JTCVS 2008 Jun;135(6):1202-9 Risk-adjusted 30-day mortality rates by CABG procedural volume in United States

12. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Expert Commentary for Japanese Cardiovascular Surgery Given the consistently low volume of most Japanese CABG programs, their overall results will come as a surprise to many. Perhaps there are lessons from this extreme example that might be applicable to less extreme but smaller programs in other countries. 12 JTCVS 2008 Jun;135(6):1202-9

13. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco How are the operative outcomes? Good operative outcomes for the smaller number of cases experienced per year Detailed operative records with schemas Pre- and post-operative discussions (with cardiologists, nurses and anesthetists) Postoperative management by CV surgeons Learn much from views and discussions in spite of less opportunity as the operator

14. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Discussion tool for high risk cardiovascular surgeries

15. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco Advantage of Japan 15 Surgeons’ collaboration in operating room Communication style in conference Operation records using drawing schemas Personalized patient management (by dedicated young CV surgeons) Inexpensive insurance for medical malpractice Easy access to cardiovascular surgeries Health-insurance system that covers all of its citizens

16. ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco However,

17. Young Japanese CV surgeons Are not satisfied with the current status in Japan –Need to share the technical tips and pitfalls –Want to share information about the international status of the same professionals –Are eager for more opportunities of clinical practice as the operator, not as the intensivists –Want a little better work-life balance, if possible Inspired by the last ISMICS International Fellow and Residents Meeting, three young Japanese CV surgeons took the gloves off for ‘INNOVATION’.