1. SIDHU P. GANGADHARAN, MD Chief, Division of Thoracic Surgery and Interventional Pulmonology BETH ISRAEL DEACONESS MEDICAL CENTER BOSTON, MA W HO SHOULD BE RESPONSIBLE FOR THE INITIAL DIAGNOSIS AND STAGING OF LUNG CANCER ? NON-SURGEONS

2. SIDHU P. GANGADHARAN, MD Chief, Division of Thoracic Surgery and Interventional Pulmonology BETH ISRAEL DEACONESS MEDICAL CENTER BOSTON, MA W HO SHOULD BE RESPONSIBLE FOR THE INITIAL DIAGNOSIS AND STAGING OF LUNG CANCER ? NON-SURGEONS NOT ONLY

3. Outline of arguments Expertise Finances

4. Venn diagrams

5. Harvard graduates US Presidents

6. Venn diagrams Plays that score touchdowns on second and goal from the 2 yard line Safe plays Run plays Wilson to Lockette, INT by Butler

7. Venn diagrams Surgeons OnlyInclude Non-surgeons Interventional pulmonology Radiology General practioner GI

8. Moving beyond wars of turf Control of work-up Control of treatment Issues of expertise

9. Specter of cardiac angiography Ownership argument Slippery slope argument Technique argument Control of work-up

10. Multidisciplinary cancer care Ownership of the lung cancer patient Bjegovich-Weidman M. J Oncol Pract. 2010 Nov;6(6):e27-30.

11. Should surgeons do brain biopsies? Diagnosis of advanced cancer Jemal A. CA Cancer J Clin 2010;60:277-300.

12. Performance profile of biopsy Low yield FNA Early stage lesions Shimizu K. Lung Cancer 2006;51:173–179.

13. Performance profile of biopsy Early stage lesions Shimizu K. Lung Cancer 2006;51:173–179.

14. Hammer/nail does not apply Ownership is linked to treatment, not work-up Many patients present with advanced disease not requiring interventional work-up Many patients with early stage only managed by surgeon Multidisciplinary team approach logical Ownership

15. Will surgical treatment decline? Staging and diagnosis already encompasses multiple non-surgical areas Clear line between work-up and treatment Adapt with technology (vascular vs. cardiac) Rules of engagement are crucial Radiation oncology Endobronchial therapy Not unique to AMC Slippery slope considerations

16. Who does it better? Learning curve Technique Hu Y. J Thorac Cardiovasc Surg 2013;146:1387-92 Stather M. Respirology (2015) 20, 333–339

17. Who does it better? Limited numbers in general practice BIDMC 400 EBUS FY2014 75% lung cancer staging/dx Technique Hu Y. J Thorac Cardiovasc Surg 2013;146:1387-92 Stather M. Respirology (2015) 20, 333–339

18. Is the pie big enough to share? Impact on individual P/L Impact on institutional bottom line Issues of finances

19. EBUS contributes to medical center bottom line $24,742/NP EBUS referral $19,174 technical fee/NP EBUS Downstream revenue Pastis N. CHEST 2012;141(2):506-512

20. EBUS contributes to medical center bottom line Technical fee per EBUS much lower High volume tertiary care setting results may not be transferable Assumption about EBUS driving NP volume Weakness of argument

21. Thoracic surgery contributes to hospital bottom line Contribution margin/wRVU Resnick A. Ann Surg 2005;242: 530–539

22. Thoracic surgery contributes to hospital bottom line Margin higher without diagnostic/staging procedures BIDMC contribution margin TS >IP wRVU/case 4-5x more McKenna R. Ann Thorac Surg 2007;84:1663-1668

23. Summary Intake and treatment determines ownership Responsibility is not exclusive Many diagnostic/staging procedures logically done by non-surgeons Many patients undergo diagnostic/staging at the time up upfront resection Fear of loss of treatment authority mitigated by multidisciplinary care Increased surgeon profitability with higher proportion of procedures that non-surgeons cannot do Why non-surgeons should have responsibility for diagnosis and staging

24. THANK YOU sgangadh@bidmc.harvard.edu 617.632.8252