AW: [HSF] Percutaneous Valves

Tue Feb 6 21:05:46 EST 2007

Thank you, Jacob, for your response. I try to say the most provocative things to start a conversation to point out my errors (even if I also believe them), but usually it is silence. I am praying to develop schizophrenia, so that I may have someone to talk to.

Surgeons are not only geographically maldistributed, but also institutionally and thirdly malpositioned in terms of prevalence. Patients in NYC may never get the benefit of a surgeon who offices one story from his internist because of the walls we erect cognitively and socially around ourselves. As Ben says, "Reality is not what meets the eye." (Or something similarly poetic, but scientifically flawed.) 

Our HSF founder provides service in possibly a two horse town. (I think that he has two horses.) IF he leaves, not only do patients not get CAB, but they get no emergent PCI based on "big box" (large volume) theories. Our value to patients is complex as described by Jacob. The OR part for you younger surgeons is often the easiest part. Go set up your own program and see. Cleveland Clinic (CC) may have 1/2 my mortality for CAB (I would be happy to debate that issue), but 1% roughly (half my mortality of primary CAB) of say 200,000 CAB a year is 2000 deaths. If all the patients with AMI have to be sent to "CC" for emergent PCI how many lives are lost? A 5% absolute difference in 900,000 Acute MIs is 45,000. (so what if I am off by a factor of say 2?) This is part of what I mean about "value". Just for my self respect, I would like to point out at last check several years ago the Cleveland affiliated programs had twice my mortality, so I don't think mortality is a strictly a
 "gnosis" problem. As usual I may be wrong... and certainly vulnerable.

This is why I think trying and thinking about novel solutions, solutions that challenge accepted norms such as my interest in CHF and CMR, is so helpful to our specialty. That way, particularly if you are blessed with schizophrenia, you may help a "close" friend with whom you can talk about solving his problems.

Tea

----- Original Message ----
From: "NielsB at aol.com" <NielsB at aol.com>
To: OpenHeart-L at lists.hsforum.com
Sent: Tuesday, February 6, 2007 4:56:43 AM
Subject: Re: AW: [HSF] Percutaneous Valves

I would like to put another little spin on Teas very interesting comments. 
The observation about undersupply of cardiac surgeon on a global basis is of 
course both appropiate and correct. It   is very important to take this a little 
further to get some global perspective on this.

The data I will present here is not accurate but pulled out of my   memory.

1) CABG in US cost   at least about 25000 $, in Bosnia where I now work 7500 
$ and in India   I have talked to hospitals that can do it for 2500 and 
balance the budget.
2) An average car in the US cost at least about 25000$ and if it is made in 
US 5000 of those are health care.
3) Therefore GM does better producing cars in the low cost countries where 
salaries are low and health care costs even lower.
4) What type of work can the car people do in the US and the West , maybe 
more design inventions and development, and organize   production in other 
countries.
5) So for production workers it is not so easy in US (or Western Europe.
6) Most of us cardiac surgeons are production workers I am sorry to say and 
we may easily go the way of the carworkers if we dont change a little bit. Do 
we really think that we as cardiac surgeons in the USA are so much better than  
a cardiac surgeon in other countries, I dare to say no, I have met as 
probably most of you top level people from all over the world. What we have in the 
US is (at least in some areas)   superior organization, (to a large extent) 
lack of corruption?   good education, excellent CMEs, good implantables etc.

I have worked now for 12 years building a cardiac clinic in Bosnia and 
Herzegovina with my friend and collegue Emir Kabil, one of the most talented 
surgeons I have met. We are now doing reasonably well. Problems are usually not the 
surgery but everything around. To come in to an established program and do some 
operations is not so difficult, but to set up the whole system is quite a 
job. And of course most of the places politics get involved.

7) But if it is anything the USA can do well it is innovation and new ideas. 
Basically if Coca Cola and medical devices and IPODs can be exported to 
anywhere in the world, efficient cardiac surgery also can ( of course we should 
import ideas as well).

8) In principle I dont think it should be so much more difficult to export a 
cardiac center model or an organizational model to other countries, and anyway 
I believe we should be part of some   global effort to offer our services to 
more people and preferably not as   "medical tourists". 

And finally watch out US is starting to export patients to other countries 
due to prices, and I think the quality in many places are not inferior either.

Jacob Bergsland

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