Sanford M. Zeigler, MD

The era of the Affordable Care Act is upon us, and short of an unlikely repeal following midterm elections, this will remain the law of the land. As surgical residents, most of us have neither the time nor mental stamina to become significantly entrenched in politics. As a result, many of us know less about the impact that the Affordable Care Act will have on our future livelihood than many of the Senators did when they passed the bill on December 24, 2009. While most of the public focus has been on the individual mandate, pre-existing conditions, and insurance exchanges, further hidden from the public eye are the methods by which our fundamental model for health care reimbursement will change.

Much of the mystery was dispelled for me this May, when I heard a lecture entitled "The Perfect Storm: The Affordable Care Act and the Repeal of the SGR" by Dr. Jeffrey Rich. Dr. Rich’s presentation was the 2014 Norman E. Shumway, MD, Visiting Professorship Lecture at Stanford (Calif.) University, a webcast of which is available at http://ctsurgery.stanford.edu/media/.

Dr. Rich has a unique perspective on the issue of health care reimbursement, as he has served both as president of STS from 2012-2013 and director of the Center for Medicare Management, part of the Centers for Medicare & Medicaid Services, in 2008, in the political tumult leading up to the passage of the Affordable Care Act. On top of this, he has remained a practicing cardiothoracic surgeon in the Sentara Health System and sits as director-at-large for the Virginia Cardiac Surgery Quality Initiative. It is impossible to overstate the impact that he and his staff have had on the future of health care reimbursement. His recent lecture highlighted the ideological change in payment models that the Affordable Care Act embodies, along with the carrots and the sticks that the government will be wielding over the next 5 years to change physician and hospital behavior. This, along with the untenable continuation of the Sustainable Growth Rate (SGR) with all of its problems, portends huge swings both positive and negative for the reimbursement of all doctors, and cardiothoracic surgeons in particular. Early adopters may find themselves with a much-needed windfall, while those who do not anticipate the changes may find themselves in dire financial straits.

First, let us examine where we stand. The United States spends 17.6% of its gross domestic product (GDP) on health care. The nearest rival sits at 12%. State and federal government together spent $1.5 trillion on health care in 2013. Add private insurance into the mix and the figure is $2.8 trillion. Our life expectancy has not followed the money, and the rate of increase in health care spending is far outstripping inflation and the growth in our GDP. Our spending has increased exponentially since the passage of the Social Security Amendments of 1965 and shows no sign of slowing down. These statistics are well publicized, and should no longer be a surprise to anyone.

Keeping in mind that hindsight is 20/20, it seems obvious how we got here. The private health insurance industry took off during WWII, when competitive wage controls were put in place to keep skilled laborers in jobs supporting the war effort. To compete for laborers, private sector employers began offering health insurance policies. Shortly thereafter, public pressure to provide a health care safety net culminated in the creation of Medicare and Medicaid in 1965, and our complex public/private health insurance environment was born. For the first decade or so, physician reimbursement was based on "reasonable charge," meaning that doctors sent a bill to Medicare and, if it was considered reasonable, the doctor was paid. This fee-for-service model can be seen as a blank check of sorts, in that it contained few stipulations to withhold repayment for redundant or unnecessary tests and procedures. Expenses associated with complications also were reimbursable. The incentive to "do more" was set. It is worth noting that the Social Security Amendments of 1965 are federal law, and the law stipulates that reimbursement is tied to the amount of work that a physician performs, which also forbids associating reimbursement with the quality of work that the physician produces. It takes an act of Congress to change such law.

The Affordable Care Act is that act. Dr. Rich’s work at CMS paved the way for the inclusion of "Title III: Improving the quality and efficiency of health care," which allows Medicare and Medicaid reimbursements to be altered based on efficiency and outcomes, moving away (although not disintegrating) the fee-for-service model. It incentivizes the development of Accountable Care Organizations and Clinically Integrated Networks to encourage cross-specialty collaboration within the fee-for-service model and lays the groundwork for physician and hospital reimbursement to be based on high-quality, efficient, and appropriate care.

This is the most comprehensive change to the status quo, but it is by no means the first. By 1975, the federal government could see that open fee-for-service was leading to skyrocketing health care costs. It began experimenting with ways to curb physician charges. It pegged reimbursements to the Medicare Economic Index (still used to update hospital reimbursements by 3.2%-3.6% per year) and then tried basing reimbursement on relative value units. Costs continued to rise. Thirty years after the 1965 law, as health care spending continued to spiral out of control, the Sustainable Growth Rate was applied to physician repayment as an attempt to reel it in. The basic premise was that increased costs from increased patient and procedure volume would be curbed by decreasing the reimbursement per procedure.

The sustainable growth model essentially placed a spending target that would grow in step with GDP using the total expenditures beginning in 1996 as a benchmark. If, during a given year, spending outstripped the target, the following year a compensatory decrease in physician reimbursement would be enacted. If spending were less than the target, then physician payments would increase. Expenditures have exceeded the target every year since 2002, and each year our spending gets further and further from the benchmark, compounding the penalty. If the SGR penalties were allowed, it is estimated that physician repayment would drop by 25%-35% in the next few years. Each time the penalty is about to be applied, a fix is passed by Congress, saving our livelihoods at the last minute. Although we should be thankful not to take a 35% pay cut, the SGR and its fixes increased physician repayment by a mere 5.1% between 1992 and 2012. For comparison, Social Security benefits, adjusted annually to compensate increasing cost of living, have risen 52.9% in the same period. Meanwhile, as I mentioned earlier, hospital reimbursement continues to be tied to the Medicare Economic Index, which yields a fairly predictable payment increase of 3.2%-3.6% each year. The Affordable Care Act operates as a law separate from the SGR law, though the two are closely intertwined.

Title III of the Affordable Care Act provides a number of new incentives and penalties that will help make efficiency and quality goals that affect profit at least as much as procedural volume. It will impact hospitals and physicians in a number of new and potentially positive ways. Most immediately concerning to hospitals and medical groups are the incentives for quality. With value-based purchasing, Medicare will withhold 2% of diagnosis-related group (DRG) reimbursements to hospitals at the beginning of a year, giving them the chance to earn it back at the end of the year if they meet quality and efficiency performance goals. The top performers will receive a bonus from the funds collected from those who do not meet goals, making this a budget-neutral operation. Cardiothoracic surgeons will feel this scrutiny early, as the first five DRGs subject to the law are acute myocardial infarction, heart failure, pneumonia, surgeries, and health care–associated infections. As time passes, more diagnoses will be added.

Payments will be based on bundled care, meaning that a hospital will be paid one sum to cover the peri-admission period, starting from 3 days prior to 30 days after admission. Complications, readmissions, and repeat tests will not generate additional funds for the hospital. You can expect that daily chest x-rays and multiple echocardiograms will generate a lot of e-mails to attending physicians. Other preventable hospital-acquired conditions, such as catheter-associated urinary tract infections and pressure ulcers, if present in rates beyond the norm for the country, could cut reimbursements an additional 1%. Patient satisfaction scores will influence hospital reimbursement. Readmission rates beyond the specified cutoff for each admission will result in a 3% hospital pay cut, again, starting with the same set of diagnoses. When meaningful use of electronic health records incentives are factored in, hospitals are looking at a 7% swing on reimbursements for the DRGs listed above by 2017. Hospitals typically operate on a profit margin around 3.5%.

On the individual physician level, there are a number of changes. Already in place was a bonus for participating in physician quality reporting systems (PQRS), such as the STS database. By 2016 the bonus for participating will become a 2% pay cut for not participating. Thankfully, our specialty has been forward thinking in this regard, and the majority of cardiothoracic practices already participate in the STS database. Similar to value-based purchasing, the physician value modifier will apply a 2% bonus or penalty to reimbursements, based on a broad spectrum of quality measures, including patient safety, population and community health, total cost per patient by condition, and patient experience. Again, this will be budget neutral. When all of the items are tallied, the lowest-performing providers could see a 6% decrease in their personal reimbursement.

The SGR has not been fixed with the Affordable Care Act. Dr. Rich, in his role as STS president, provided testimony to Congress leading up to the most recent attempt to reform the law. Part of the main thrust of his testimony was that each specialty needs to set its own outcomes standards through database-driven research. Incentives for improved outcomes need to be in place for all members of the heart team, not just the physicians. All three of the proposed bills that followed his testimony included such incentives, but they also included even more dismal updates to physician payments than we have seen in the past 20 years. For better or for worse, none of the bills passed, and we can look forward to more anxiety as we await the next SGR patch. Whatever durable solution passes will likely focus on these new models of payment but without a significant boost in hospital income.

Currently, the alternative payment model (APM) pilot programs are still being developed. CMS has a $10 billion budget to fund the pilot programs, and consulting groups that advised the agency chose cardiothoracic surgery as a top priority for APM development. Current discussions indicate that participants in APMs could get a 5% bonus and would not be subject to the physician value modifier.

So how does this apply to us residents? Despite our ground-level perspective, we must recognize that we are straddling two drastically different eras in the practice of medicine. It will be the duty of all of us, not just our attendings, to reduce our costs and provide better patient care. This may mean using our stethoscope more effectively or making those extra phone calls to avoid unnecessary or repeated tests. We need to rebel against the ideology of physician shift work by owning our patients, but still work effectively in that system. When it comes time to seek our first jobs, we should focus not just on the department that we will work on, but its context within the local hospital system. The most vibrant department within an unresponsive hospital system will drown in the future penalties, and likewise for an unenthusiastic department within a forward-thinking system. In short, we need to start training ourselves to be keener, sharper, and more agile physicians, and to position ourselves within like-minded environments. Perhaps more important than any of these, we need to reclaim the right to shape our own profession. In recent history there has not been a better opportunity for cardiothoracic surgeons as a group to assert themselves as adept physicians and leaders. Whether we become head of CMS, participate in STS fly-ins to Capitol Hill, write our congressman about the issues we face, or engage our hospitals to anticipate the coming changes, it is up to us to ensure that we have a future.

Dr. Zeigler is one of the outgoing resident medical editors for Thoracic Surgery News.

The era of the Affordable Care Act is upon us, and short of an unlikely repeal following midterm elections, this will remain the law of the land. As surgical residents, most of us have neither the time nor mental stamina to become significantly entrenched in politics. As a result, many of us know less about the impact that the Affordable Care Act will have on our future livelihood than many of the Senators did when they passed the bill on December 24, 2009. While most of the public focus has been on the individual mandate, pre-existing conditions, and insurance exchanges, further hidden from the public eye are the methods by which our fundamental model for health care reimbursement will change.

Much of the mystery was dispelled for me this May, when I heard a lecture entitled "The Perfect Storm: The Affordable Care Act and the Repeal of the SGR" by Dr. Jeffrey Rich. Dr. Rich’s presentation was the 2014 Norman E. Shumway, MD, Visiting Professorship Lecture at Stanford (Calif.) University, a webcast of which is available at http://ctsurgery.stanford.edu/media/.

Dr. Rich has a unique perspective on the issue of health care reimbursement, as he has served both as president of STS from 2012-2013 and director of the Center for Medicare Management, part of the Centers for Medicare & Medicaid Services, in 2008, in the political tumult leading up to the passage of the Affordable Care Act. On top of this, he has remained a practicing cardiothoracic surgeon in the Sentara Health System and sits as director-at-large for the Virginia Cardiac Surgery Quality Initiative. It is impossible to overstate the impact that he and his staff have had on the future of health care reimbursement. His recent lecture highlighted the ideological change in payment models that the Affordable Care Act embodies, along with the carrots and the sticks that the government will be wielding over the next 5 years to change physician and hospital behavior. This, along with the untenable continuation of the Sustainable Growth Rate (SGR) with all of its problems, portends huge swings both positive and negative for the reimbursement of all doctors, and cardiothoracic surgeons in particular. Early adopters may find themselves with a much-needed windfall, while those who do not anticipate the changes may find themselves in dire financial straits.

First, let us examine where we stand. The United States spends 17.6% of its gross domestic product (GDP) on health care. The nearest rival sits at 12%. State and federal government together spent $1.5 trillion on health care in 2013. Add private insurance into the mix and the figure is $2.8 trillion. Our life expectancy has not followed the money, and the rate of increase in health care spending is far outstripping inflation and the growth in our GDP. Our spending has increased exponentially since the passage of the Social Security Amendments of 1965 and shows no sign of slowing down. These statistics are well publicized, and should no longer be a surprise to anyone.

Keeping in mind that hindsight is 20/20, it seems obvious how we got here. The private health insurance industry took off during WWII, when competitive wage controls were put in place to keep skilled laborers in jobs supporting the war effort. To compete for laborers, private sector employers began offering health insurance policies. Shortly thereafter, public pressure to provide a health care safety net culminated in the creation of Medicare and Medicaid in 1965, and our complex public/private health insurance environment was born. For the first decade or so, physician reimbursement was based on "reasonable charge," meaning that doctors sent a bill to Medicare and, if it was considered reasonable, the doctor was paid. This fee-for-service model can be seen as a blank check of sorts, in that it contained few stipulations to withhold repayment for redundant or unnecessary tests and procedures. Expenses associated with complications also were reimbursable. The incentive to "do more" was set. It is worth noting that the Social Security Amendments of 1965 are federal law, and the law stipulates that reimbursement is tied to the amount of work that a physician performs, which also forbids associating reimbursement with the quality of work that the physician produces. It takes an act of Congress to change such law.

The Affordable Care Act is that act. Dr. Rich’s work at CMS paved the way for the inclusion of "Title III: Improving the quality and efficiency of health care," which allows Medicare and Medicaid reimbursements to be altered based on efficiency and outcomes, moving away (although not disintegrating) the fee-for-service model. It incentivizes the development of Accountable Care Organizations and Clinically Integrated Networks to encourage cross-specialty collaboration within the fee-for-service model and lays the groundwork for physician and hospital reimbursement to be based on high-quality, efficient, and appropriate care.

This is the most comprehensive change to the status quo, but it is by no means the first. By 1975, the federal government could see that open fee-for-service was leading to skyrocketing health care costs. It began experimenting with ways to curb physician charges. It pegged reimbursements to the Medicare Economic Index (still used to update hospital reimbursements by 3.2%-3.6% per year) and then tried basing reimbursement on relative value units. Costs continued to rise. Thirty years after the 1965 law, as health care spending continued to spiral out of control, the Sustainable Growth Rate was applied to physician repayment as an attempt to reel it in. The basic premise was that increased costs from increased patient and procedure volume would be curbed by decreasing the reimbursement per procedure.

The sustainable growth model essentially placed a spending target that would grow in step with GDP using the total expenditures beginning in 1996 as a benchmark. If, during a given year, spending outstripped the target, the following year a compensatory decrease in physician reimbursement would be enacted. If spending were less than the target, then physician payments would increase. Expenditures have exceeded the target every year since 2002, and each year our spending gets further and further from the benchmark, compounding the penalty. If the SGR penalties were allowed, it is estimated that physician repayment would drop by 25%-35% in the next few years. Each time the penalty is about to be applied, a fix is passed by Congress, saving our livelihoods at the last minute. Although we should be thankful not to take a 35% pay cut, the SGR and its fixes increased physician repayment by a mere 5.1% between 1992 and 2012. For comparison, Social Security benefits, adjusted annually to compensate increasing cost of living, have risen 52.9% in the same period. Meanwhile, as I mentioned earlier, hospital reimbursement continues to be tied to the Medicare Economic Index, which yields a fairly predictable payment increase of 3.2%-3.6% each year. The Affordable Care Act operates as a law separate from the SGR law, though the two are closely intertwined.

Title III of the Affordable Care Act provides a number of new incentives and penalties that will help make efficiency and quality goals that affect profit at least as much as procedural volume. It will impact hospitals and physicians in a number of new and potentially positive ways. Most immediately concerning to hospitals and medical groups are the incentives for quality. With value-based purchasing, Medicare will withhold 2% of diagnosis-related group (DRG) reimbursements to hospitals at the beginning of a year, giving them the chance to earn it back at the end of the year if they meet quality and efficiency performance goals. The top performers will receive a bonus from the funds collected from those who do not meet goals, making this a budget-neutral operation. Cardiothoracic surgeons will feel this scrutiny early, as the first five DRGs subject to the law are acute myocardial infarction, heart failure, pneumonia, surgeries, and health care–associated infections. As time passes, more diagnoses will be added.

Payments will be based on bundled care, meaning that a hospital will be paid one sum to cover the peri-admission period, starting from 3 days prior to 30 days after admission. Complications, readmissions, and repeat tests will not generate additional funds for the hospital. You can expect that daily chest x-rays and multiple echocardiograms will generate a lot of e-mails to attending physicians. Other preventable hospital-acquired conditions, such as catheter-associated urinary tract infections and pressure ulcers, if present in rates beyond the norm for the country, could cut reimbursements an additional 1%. Patient satisfaction scores will influence hospital reimbursement. Readmission rates beyond the specified cutoff for each admission will result in a 3% hospital pay cut, again, starting with the same set of diagnoses. When meaningful use of electronic health records incentives are factored in, hospitals are looking at a 7% swing on reimbursements for the DRGs listed above by 2017. Hospitals typically operate on a profit margin around 3.5%.

On the individual physician level, there are a number of changes. Already in place was a bonus for participating in physician quality reporting systems (PQRS), such as the STS database. By 2016 the bonus for participating will become a 2% pay cut for not participating. Thankfully, our specialty has been forward thinking in this regard, and the majority of cardiothoracic practices already participate in the STS database. Similar to value-based purchasing, the physician value modifier will apply a 2% bonus or penalty to reimbursements, based on a broad spectrum of quality measures, including patient safety, population and community health, total cost per patient by condition, and patient experience. Again, this will be budget neutral. When all of the items are tallied, the lowest-performing providers could see a 6% decrease in their personal reimbursement.

The SGR has not been fixed with the Affordable Care Act. Dr. Rich, in his role as STS president, provided testimony to Congress leading up to the most recent attempt to reform the law. Part of the main thrust of his testimony was that each specialty needs to set its own outcomes standards through database-driven research. Incentives for improved outcomes need to be in place for all members of the heart team, not just the physicians. All three of the proposed bills that followed his testimony included such incentives, but they also included even more dismal updates to physician payments than we have seen in the past 20 years. For better or for worse, none of the bills passed, and we can look forward to more anxiety as we await the next SGR patch. Whatever durable solution passes will likely focus on these new models of payment but without a significant boost in hospital income.

Currently, the alternative payment model (APM) pilot programs are still being developed. CMS has a $10 billion budget to fund the pilot programs, and consulting groups that advised the agency chose cardiothoracic surgery as a top priority for APM development. Current discussions indicate that participants in APMs could get a 5% bonus and would not be subject to the physician value modifier.

So how does this apply to us residents? Despite our ground-level perspective, we must recognize that we are straddling two drastically different eras in the practice of medicine. It will be the duty of all of us, not just our attendings, to reduce our costs and provide better patient care. This may mean using our stethoscope more effectively or making those extra phone calls to avoid unnecessary or repeated tests. We need to rebel against the ideology of physician shift work by owning our patients, but still work effectively in that system. When it comes time to seek our first jobs, we should focus not just on the department that we will work on, but its context within the local hospital system. The most vibrant department within an unresponsive hospital system will drown in the future penalties, and likewise for an unenthusiastic department within a forward-thinking system. In short, we need to start training ourselves to be keener, sharper, and more agile physicians, and to position ourselves within like-minded environments. Perhaps more important than any of these, we need to reclaim the right to shape our own profession. In recent history there has not been a better opportunity for cardiothoracic surgeons as a group to assert themselves as adept physicians and leaders. Whether we become head of CMS, participate in STS fly-ins to Capitol Hill, write our congressman about the issues we face, or engage our hospitals to anticipate the coming changes, it is up to us to ensure that we have a future.

Dr. Zeigler is one of the outgoing resident medical editors for Thoracic Surgery News.

The era of the Affordable Care Act is upon us, and short of an unlikely repeal following midterm elections, this will remain the law of the land. As surgical residents, most of us have neither the time nor mental stamina to become significantly entrenched in politics. As a result, many of us know less about the impact that the Affordable Care Act will have on our future livelihood than many of the Senators did when they passed the bill on December 24, 2009. While most of the public focus has been on the individual mandate, pre-existing conditions, and insurance exchanges, further hidden from the public eye are the methods by which our fundamental model for health care reimbursement will change.

Much of the mystery was dispelled for me this May, when I heard a lecture entitled "The Perfect Storm: The Affordable Care Act and the Repeal of the SGR" by Dr. Jeffrey Rich. Dr. Rich’s presentation was the 2014 Norman E. Shumway, MD, Visiting Professorship Lecture at Stanford (Calif.) University, a webcast of which is available at http://ctsurgery.stanford.edu/media/.

Dr. Rich has a unique perspective on the issue of health care reimbursement, as he has served both as president of STS from 2012-2013 and director of the Center for Medicare Management, part of the Centers for Medicare & Medicaid Services, in 2008, in the political tumult leading up to the passage of the Affordable Care Act. On top of this, he has remained a practicing cardiothoracic surgeon in the Sentara Health System and sits as director-at-large for the Virginia Cardiac Surgery Quality Initiative. It is impossible to overstate the impact that he and his staff have had on the future of health care reimbursement. His recent lecture highlighted the ideological change in payment models that the Affordable Care Act embodies, along with the carrots and the sticks that the government will be wielding over the next 5 years to change physician and hospital behavior. This, along with the untenable continuation of the Sustainable Growth Rate (SGR) with all of its problems, portends huge swings both positive and negative for the reimbursement of all doctors, and cardiothoracic surgeons in particular. Early adopters may find themselves with a much-needed windfall, while those who do not anticipate the changes may find themselves in dire financial straits.

First, let us examine where we stand. The United States spends 17.6% of its gross domestic product (GDP) on health care. The nearest rival sits at 12%. State and federal government together spent $1.5 trillion on health care in 2013. Add private insurance into the mix and the figure is $2.8 trillion. Our life expectancy has not followed the money, and the rate of increase in health care spending is far outstripping inflation and the growth in our GDP. Our spending has increased exponentially since the passage of the Social Security Amendments of 1965 and shows no sign of slowing down. These statistics are well publicized, and should no longer be a surprise to anyone.

Keeping in mind that hindsight is 20/20, it seems obvious how we got here. The private health insurance industry took off during WWII, when competitive wage controls were put in place to keep skilled laborers in jobs supporting the war effort. To compete for laborers, private sector employers began offering health insurance policies. Shortly thereafter, public pressure to provide a health care safety net culminated in the creation of Medicare and Medicaid in 1965, and our complex public/private health insurance environment was born. For the first decade or so, physician reimbursement was based on "reasonable charge," meaning that doctors sent a bill to Medicare and, if it was considered reasonable, the doctor was paid. This fee-for-service model can be seen as a blank check of sorts, in that it contained few stipulations to withhold repayment for redundant or unnecessary tests and procedures. Expenses associated with complications also were reimbursable. The incentive to "do more" was set. It is worth noting that the Social Security Amendments of 1965 are federal law, and the law stipulates that reimbursement is tied to the amount of work that a physician performs, which also forbids associating reimbursement with the quality of work that the physician produces. It takes an act of Congress to change such law.

The Affordable Care Act is that act. Dr. Rich’s work at CMS paved the way for the inclusion of "Title III: Improving the quality and efficiency of health care," which allows Medicare and Medicaid reimbursements to be altered based on efficiency and outcomes, moving away (although not disintegrating) the fee-for-service model. It incentivizes the development of Accountable Care Organizations and Clinically Integrated Networks to encourage cross-specialty collaboration within the fee-for-service model and lays the groundwork for physician and hospital reimbursement to be based on high-quality, efficient, and appropriate care.

This is the most comprehensive change to the status quo, but it is by no means the first. By 1975, the federal government could see that open fee-for-service was leading to skyrocketing health care costs. It began experimenting with ways to curb physician charges. It pegged reimbursements to the Medicare Economic Index (still used to update hospital reimbursements by 3.2%-3.6% per year) and then tried basing reimbursement on relative value units. Costs continued to rise. Thirty years after the 1965 law, as health care spending continued to spiral out of control, the Sustainable Growth Rate was applied to physician repayment as an attempt to reel it in. The basic premise was that increased costs from increased patient and procedure volume would be curbed by decreasing the reimbursement per procedure.

The sustainable growth model essentially placed a spending target that would grow in step with GDP using the total expenditures beginning in 1996 as a benchmark. If, during a given year, spending outstripped the target, the following year a compensatory decrease in physician reimbursement would be enacted. If spending were less than the target, then physician payments would increase. Expenditures have exceeded the target every year since 2002, and each year our spending gets further and further from the benchmark, compounding the penalty. If the SGR penalties were allowed, it is estimated that physician repayment would drop by 25%-35% in the next few years. Each time the penalty is about to be applied, a fix is passed by Congress, saving our livelihoods at the last minute. Although we should be thankful not to take a 35% pay cut, the SGR and its fixes increased physician repayment by a mere 5.1% between 1992 and 2012. For comparison, Social Security benefits, adjusted annually to compensate increasing cost of living, have risen 52.9% in the same period. Meanwhile, as I mentioned earlier, hospital reimbursement continues to be tied to the Medicare Economic Index, which yields a fairly predictable payment increase of 3.2%-3.6% each year. The Affordable Care Act operates as a law separate from the SGR law, though the two are closely intertwined.

Title III of the Affordable Care Act provides a number of new incentives and penalties that will help make efficiency and quality goals that affect profit at least as much as procedural volume. It will impact hospitals and physicians in a number of new and potentially positive ways. Most immediately concerning to hospitals and medical groups are the incentives for quality. With value-based purchasing, Medicare will withhold 2% of diagnosis-related group (DRG) reimbursements to hospitals at the beginning of a year, giving them the chance to earn it back at the end of the year if they meet quality and efficiency performance goals. The top performers will receive a bonus from the funds collected from those who do not meet goals, making this a budget-neutral operation. Cardiothoracic surgeons will feel this scrutiny early, as the first five DRGs subject to the law are acute myocardial infarction, heart failure, pneumonia, surgeries, and health care–associated infections. As time passes, more diagnoses will be added.

Payments will be based on bundled care, meaning that a hospital will be paid one sum to cover the peri-admission period, starting from 3 days prior to 30 days after admission. Complications, readmissions, and repeat tests will not generate additional funds for the hospital. You can expect that daily chest x-rays and multiple echocardiograms will generate a lot of e-mails to attending physicians. Other preventable hospital-acquired conditions, such as catheter-associated urinary tract infections and pressure ulcers, if present in rates beyond the norm for the country, could cut reimbursements an additional 1%. Patient satisfaction scores will influence hospital reimbursement. Readmission rates beyond the specified cutoff for each admission will result in a 3% hospital pay cut, again, starting with the same set of diagnoses. When meaningful use of electronic health records incentives are factored in, hospitals are looking at a 7% swing on reimbursements for the DRGs listed above by 2017. Hospitals typically operate on a profit margin around 3.5%.

On the individual physician level, there are a number of changes. Already in place was a bonus for participating in physician quality reporting systems (PQRS), such as the STS database. By 2016 the bonus for participating will become a 2% pay cut for not participating. Thankfully, our specialty has been forward thinking in this regard, and the majority of cardiothoracic practices already participate in the STS database. Similar to value-based purchasing, the physician value modifier will apply a 2% bonus or penalty to reimbursements, based on a broad spectrum of quality measures, including patient safety, population and community health, total cost per patient by condition, and patient experience. Again, this will be budget neutral. When all of the items are tallied, the lowest-performing providers could see a 6% decrease in their personal reimbursement.

The SGR has not been fixed with the Affordable Care Act. Dr. Rich, in his role as STS president, provided testimony to Congress leading up to the most recent attempt to reform the law. Part of the main thrust of his testimony was that each specialty needs to set its own outcomes standards through database-driven research. Incentives for improved outcomes need to be in place for all members of the heart team, not just the physicians. All three of the proposed bills that followed his testimony included such incentives, but they also included even more dismal updates to physician payments than we have seen in the past 20 years. For better or for worse, none of the bills passed, and we can look forward to more anxiety as we await the next SGR patch. Whatever durable solution passes will likely focus on these new models of payment but without a significant boost in hospital income.

Currently, the alternative payment model (APM) pilot programs are still being developed. CMS has a $10 billion budget to fund the pilot programs, and consulting groups that advised the agency chose cardiothoracic surgery as a top priority for APM development. Current discussions indicate that participants in APMs could get a 5% bonus and would not be subject to the physician value modifier.

So how does this apply to us residents? Despite our ground-level perspective, we must recognize that we are straddling two drastically different eras in the practice of medicine. It will be the duty of all of us, not just our attendings, to reduce our costs and provide better patient care. This may mean using our stethoscope more effectively or making those extra phone calls to avoid unnecessary or repeated tests. We need to rebel against the ideology of physician shift work by owning our patients, but still work effectively in that system. When it comes time to seek our first jobs, we should focus not just on the department that we will work on, but its context within the local hospital system. The most vibrant department within an unresponsive hospital system will drown in the future penalties, and likewise for an unenthusiastic department within a forward-thinking system. In short, we need to start training ourselves to be keener, sharper, and more agile physicians, and to position ourselves within like-minded environments. Perhaps more important than any of these, we need to reclaim the right to shape our own profession. In recent history there has not been a better opportunity for cardiothoracic surgeons as a group to assert themselves as adept physicians and leaders. Whether we become head of CMS, participate in STS fly-ins to Capitol Hill, write our congressman about the issues we face, or engage our hospitals to anticipate the coming changes, it is up to us to ensure that we have a future.

Dr. Zeigler is one of the outgoing resident medical editors for Thoracic Surgery News.

Minimally invasive cardiac surgery has experienced a meteoric rise since its development in the 1990s. The first thoracic aortic stent graft was placed in July 1992, at Stanford (Calif.) University. Five years later, the Stanford group published their approach to mitral valve surgery through a right anterior thoracotomy. Just a year later, Dr. Alain Carpentier performed the first robotic-assisted mitral valve operation.1 There has been an explosion of new techniques, broadening the cardiac surgeon’s armamentarium far beyond the typical median sternotomy and occasional left thoracotomy.

While many of these techniques will undoubtedly become historical footnotes, it is clear that minimally invasive cardiac surgery is here to stay, as 20% of mitral repairs are performed with some element of minimally invasive technique. Similarly, thoracic endovascular aortic repair has become a well-established treatment for aneurysmal disease and dissection of the thoracic aorta, and is rapidly catching up with open repair as the treatment of choice.²

Training has also changed. The last decade brought a surge of applications to traditional fellowship programs, and the integrated thoracic surgery programs graduated their first trainees last year. With the variety of new operations and techniques, novel training formats, and professional goals for cardiothoracic surgery trainees, how can we be sure that young cardiac surgeons are learning the skills they need to succeed in the coming decades?

To ask how new surgeons should learn, you must start by asking what needs to be learned. After I asked a number of different surgeons in a variety of practice set-ups, the answer became obvious, and it is deceptively basic. The purpose of training is simply to ensure that each trainee can do all of the commonly performed operations of their specialty. This includes open valve and coronary surgery on the cardiac side, while for thoracic surgery, this includes all of the traditional lung and esophageal resections, chest wall and pleural operations, and importantly, the widely practiced VATS lobectomy. When I asked about more advanced VATS skills and minimally invasive cardiac skills, I was always told that those would be icing on the cake, as it were, to make a graduate more valuable to a potential employer. The first step in learning a minimally invasive operation is to understand the traditional, open approach, and VATS lung surgery is no different.

The VATS lobectomy has been a recent but well-received addition to the expected repertoire of graduates, and Dr. Chadrick Denlinger, associate professor of surgery at the Medical University of South Carolina, Charleston, allows his chief residents to take other trainees through the case, and expects that all new graduates can do one. Across the coast, Dr. Joseph Woo, newly appointed chair of cardiovascular surgery at Stanford, agrees. This expectation alone informs us that our specialty is dynamic and that the definition of an essential skill is in constant flux. On the other hand, cardiac surgery has no touchstone or standard minimally invasive procedure. However, Dr. Woo explains, the ABTS has set its recommendations in anticipation of the continued success of minimally invasive approaches to cardiovascular problems. The board doesn’t require mastery of any specific minimally invasive cardiac operation by the end of a training program, but it does require that we are exposed to a number of different endovascular and nontraditional approaches to coronary, valve, and aortic surgery. Coupled with our presumed mastery of the standard, open operations, we should then have the basic skills necessary to learn whatever minimally invasive operations we like, depending on our interests and our post-training mentorship.

Of course, the safety and efficacy of thoracic aortic stent grafting and minimally invasive mitral surgery have already been proven to some degree, and the operations aren’t going away anytime soon.^3,4 So what is stopping us from learning this stuff during our training? The answer is complicated. Dr. Woo cites the lack of visualization for two surgeons, the difficulty in preventing and controlling technical complications in a limited field, and the very nature the operations themselves.

Take, for example, the minimally invasive mitral valve repair. Its open counterpart requires a skill set that few trainees, if any, can claim mastery of until the very end of their training. The skill required, patient selection, and pathology treated make the operation sort of a "boutique" treatment. The patients that are offered right thoracotomy approach tend to be younger, less symptomatic, and with less complex disease. They have higher expectations. As Dr. Woo put it, "if you perform an absolutely perfect repair, then you’ve only done your job. But there is no way to do any better." With that sort of standard, many attending surgeons are hesitant to hand over the instruments to a trainee. Furthermore, not every resident’s technical ability lines up with what is required of that interest, and more importantly, not every resident is interested. Because of the highly specialized nature of the operation, the relatively smaller patient base, and the technical difficulty involved, it is often up to the highly motivated fellow or resident to gravitate to these repairs and seek out the training on their own.

Dr. James Fann, cofounder of the annual TSDA boot camp and a national surgical education leader, has some perspective on the matter. If residents are interested in gaining added endovascular or minimally invasive skills, he suggests, they first have to prove themselves in the operating room. When they’ve mastered the skills for an open technique and have proven they can get out of trouble, then an attending might feel comfortable letting them take on these more complex cases. It takes a combination of skill and interest – and as only a minority of trainees will have both, most training programs do not require that every TEVAR or mini-mitral be staffed with a resident.

It seems that simulation does not provide an easy shortcut beyond this approach, though it does have a role. To be honest, I expected Dr. Fann to preach the simulation gospel, and tell me about some incredible TEVAR or TAVR simulator he was getting ready to unveil, but his response was far more measured. "The role of simulation," he said, "is not to teach a resident how to operate. It is an adjunct – a tool that can be used to identify and address specific technical issues outside of the operating room." He reinforced the importance of mastering traditional surgical techniques before embarking on miniaturization. Simulation can help trainees operate more efficiently and effectively, but it cannot and should not replace mentored operative experience.

MICS simulation does exist, as anyone who has worked with Dr. L. Wiley Nifong and Dr. Randolph Chitwood’s high-fidelity tissue simulators for minimally invasive mitral valve repair knows. Simbionix USA (Cleveland) has just obtained FDA clearance for its TEVAR simulator that can be tailored to rehearse an upcoming case using a patient’s CT scan. On the lower end of the cost spectrum, a Dutch group and a separate Hannover group have developed low-cost, reproducible models of mini-mitral surgery that can be built from materials from a hardware store.⁵ Again, all of these tools are designed to be adjuncts to experiential training and mentorship, not mentors in and of themselves.

Residents can and should be exposed to TEVAR, TAVR, mini-mitral repair, and other less invasive approaches that are offered at their institution if they are interested. These, along with any other skills beyond traditional open techniques, make the surgeon better. More importantly, they help the trainee gain the basic wire and small incision skills they will need to learn quickly any newly developed operations that the changing specialty requires. They may not master the skills as a resident, but they are that much more prepared to hone those skills with their mentors when that time comes. In fact, the faculty I spoke with placed far more emphasis on mentorship after residency than aggressive residency training, simulation, and superfellowship as the key to gaining these advanced skills. Trainees should be soaking up all of the skills that they possibly can while they can, and if one is smart, ambitious, and skilled enough to become technically proficient at a more technically advanced skill, it certainly makes them a more desirable surgeon. For most of us, however, it is more important to realize that the training never truly ends, to take advantage of the opportunities afforded by residency, and to continue getting those reps in the OR.

References

1. Cardiac Surgery in the Adult, 4e. New York, N.Y.: McGraw-Hill; 2012.

2. J. Thorac. Cardiovasc. Surg. 2012; 144:612-16.

3. Circulation 2013;6:407-16.

4. Ann. Cardiothorac. Surg. 2013;2:744-50.

5. Interact. Cardiovasc. Thorac. Surg. 2013;16:97-101.

Minimally invasive cardiac surgery has experienced a meteoric rise since its development in the 1990s. The first thoracic aortic stent graft was placed in July 1992, at Stanford (Calif.) University. Five years later, the Stanford group published their approach to mitral valve surgery through a right anterior thoracotomy. Just a year later, Dr. Alain Carpentier performed the first robotic-assisted mitral valve operation.1 There has been an explosion of new techniques, broadening the cardiac surgeon’s armamentarium far beyond the typical median sternotomy and occasional left thoracotomy.

While many of these techniques will undoubtedly become historical footnotes, it is clear that minimally invasive cardiac surgery is here to stay, as 20% of mitral repairs are performed with some element of minimally invasive technique. Similarly, thoracic endovascular aortic repair has become a well-established treatment for aneurysmal disease and dissection of the thoracic aorta, and is rapidly catching up with open repair as the treatment of choice.²

Training has also changed. The last decade brought a surge of applications to traditional fellowship programs, and the integrated thoracic surgery programs graduated their first trainees last year. With the variety of new operations and techniques, novel training formats, and professional goals for cardiothoracic surgery trainees, how can we be sure that young cardiac surgeons are learning the skills they need to succeed in the coming decades?

To ask how new surgeons should learn, you must start by asking what needs to be learned. After I asked a number of different surgeons in a variety of practice set-ups, the answer became obvious, and it is deceptively basic. The purpose of training is simply to ensure that each trainee can do all of the commonly performed operations of their specialty. This includes open valve and coronary surgery on the cardiac side, while for thoracic surgery, this includes all of the traditional lung and esophageal resections, chest wall and pleural operations, and importantly, the widely practiced VATS lobectomy. When I asked about more advanced VATS skills and minimally invasive cardiac skills, I was always told that those would be icing on the cake, as it were, to make a graduate more valuable to a potential employer. The first step in learning a minimally invasive operation is to understand the traditional, open approach, and VATS lung surgery is no different.

The VATS lobectomy has been a recent but well-received addition to the expected repertoire of graduates, and Dr. Chadrick Denlinger, associate professor of surgery at the Medical University of South Carolina, Charleston, allows his chief residents to take other trainees through the case, and expects that all new graduates can do one. Across the coast, Dr. Joseph Woo, newly appointed chair of cardiovascular surgery at Stanford, agrees. This expectation alone informs us that our specialty is dynamic and that the definition of an essential skill is in constant flux. On the other hand, cardiac surgery has no touchstone or standard minimally invasive procedure. However, Dr. Woo explains, the ABTS has set its recommendations in anticipation of the continued success of minimally invasive approaches to cardiovascular problems. The board doesn’t require mastery of any specific minimally invasive cardiac operation by the end of a training program, but it does require that we are exposed to a number of different endovascular and nontraditional approaches to coronary, valve, and aortic surgery. Coupled with our presumed mastery of the standard, open operations, we should then have the basic skills necessary to learn whatever minimally invasive operations we like, depending on our interests and our post-training mentorship.

Of course, the safety and efficacy of thoracic aortic stent grafting and minimally invasive mitral surgery have already been proven to some degree, and the operations aren’t going away anytime soon.^3,4 So what is stopping us from learning this stuff during our training? The answer is complicated. Dr. Woo cites the lack of visualization for two surgeons, the difficulty in preventing and controlling technical complications in a limited field, and the very nature the operations themselves.

Take, for example, the minimally invasive mitral valve repair. Its open counterpart requires a skill set that few trainees, if any, can claim mastery of until the very end of their training. The skill required, patient selection, and pathology treated make the operation sort of a "boutique" treatment. The patients that are offered right thoracotomy approach tend to be younger, less symptomatic, and with less complex disease. They have higher expectations. As Dr. Woo put it, "if you perform an absolutely perfect repair, then you’ve only done your job. But there is no way to do any better." With that sort of standard, many attending surgeons are hesitant to hand over the instruments to a trainee. Furthermore, not every resident’s technical ability lines up with what is required of that interest, and more importantly, not every resident is interested. Because of the highly specialized nature of the operation, the relatively smaller patient base, and the technical difficulty involved, it is often up to the highly motivated fellow or resident to gravitate to these repairs and seek out the training on their own.

Dr. James Fann, cofounder of the annual TSDA boot camp and a national surgical education leader, has some perspective on the matter. If residents are interested in gaining added endovascular or minimally invasive skills, he suggests, they first have to prove themselves in the operating room. When they’ve mastered the skills for an open technique and have proven they can get out of trouble, then an attending might feel comfortable letting them take on these more complex cases. It takes a combination of skill and interest – and as only a minority of trainees will have both, most training programs do not require that every TEVAR or mini-mitral be staffed with a resident.

It seems that simulation does not provide an easy shortcut beyond this approach, though it does have a role. To be honest, I expected Dr. Fann to preach the simulation gospel, and tell me about some incredible TEVAR or TAVR simulator he was getting ready to unveil, but his response was far more measured. "The role of simulation," he said, "is not to teach a resident how to operate. It is an adjunct – a tool that can be used to identify and address specific technical issues outside of the operating room." He reinforced the importance of mastering traditional surgical techniques before embarking on miniaturization. Simulation can help trainees operate more efficiently and effectively, but it cannot and should not replace mentored operative experience.

MICS simulation does exist, as anyone who has worked with Dr. L. Wiley Nifong and Dr. Randolph Chitwood’s high-fidelity tissue simulators for minimally invasive mitral valve repair knows. Simbionix USA (Cleveland) has just obtained FDA clearance for its TEVAR simulator that can be tailored to rehearse an upcoming case using a patient’s CT scan. On the lower end of the cost spectrum, a Dutch group and a separate Hannover group have developed low-cost, reproducible models of mini-mitral surgery that can be built from materials from a hardware store.⁵ Again, all of these tools are designed to be adjuncts to experiential training and mentorship, not mentors in and of themselves.

Residents can and should be exposed to TEVAR, TAVR, mini-mitral repair, and other less invasive approaches that are offered at their institution if they are interested. These, along with any other skills beyond traditional open techniques, make the surgeon better. More importantly, they help the trainee gain the basic wire and small incision skills they will need to learn quickly any newly developed operations that the changing specialty requires. They may not master the skills as a resident, but they are that much more prepared to hone those skills with their mentors when that time comes. In fact, the faculty I spoke with placed far more emphasis on mentorship after residency than aggressive residency training, simulation, and superfellowship as the key to gaining these advanced skills. Trainees should be soaking up all of the skills that they possibly can while they can, and if one is smart, ambitious, and skilled enough to become technically proficient at a more technically advanced skill, it certainly makes them a more desirable surgeon. For most of us, however, it is more important to realize that the training never truly ends, to take advantage of the opportunities afforded by residency, and to continue getting those reps in the OR.

References

1. Cardiac Surgery in the Adult, 4e. New York, N.Y.: McGraw-Hill; 2012.

2. J. Thorac. Cardiovasc. Surg. 2012; 144:612-16.

3. Circulation 2013;6:407-16.

4. Ann. Cardiothorac. Surg. 2013;2:744-50.

5. Interact. Cardiovasc. Thorac. Surg. 2013;16:97-101.

Minimally invasive cardiac surgery has experienced a meteoric rise since its development in the 1990s. The first thoracic aortic stent graft was placed in July 1992, at Stanford (Calif.) University. Five years later, the Stanford group published their approach to mitral valve surgery through a right anterior thoracotomy. Just a year later, Dr. Alain Carpentier performed the first robotic-assisted mitral valve operation.1 There has been an explosion of new techniques, broadening the cardiac surgeon’s armamentarium far beyond the typical median sternotomy and occasional left thoracotomy.

While many of these techniques will undoubtedly become historical footnotes, it is clear that minimally invasive cardiac surgery is here to stay, as 20% of mitral repairs are performed with some element of minimally invasive technique. Similarly, thoracic endovascular aortic repair has become a well-established treatment for aneurysmal disease and dissection of the thoracic aorta, and is rapidly catching up with open repair as the treatment of choice.²

Training has also changed. The last decade brought a surge of applications to traditional fellowship programs, and the integrated thoracic surgery programs graduated their first trainees last year. With the variety of new operations and techniques, novel training formats, and professional goals for cardiothoracic surgery trainees, how can we be sure that young cardiac surgeons are learning the skills they need to succeed in the coming decades?

To ask how new surgeons should learn, you must start by asking what needs to be learned. After I asked a number of different surgeons in a variety of practice set-ups, the answer became obvious, and it is deceptively basic. The purpose of training is simply to ensure that each trainee can do all of the commonly performed operations of their specialty. This includes open valve and coronary surgery on the cardiac side, while for thoracic surgery, this includes all of the traditional lung and esophageal resections, chest wall and pleural operations, and importantly, the widely practiced VATS lobectomy. When I asked about more advanced VATS skills and minimally invasive cardiac skills, I was always told that those would be icing on the cake, as it were, to make a graduate more valuable to a potential employer. The first step in learning a minimally invasive operation is to understand the traditional, open approach, and VATS lung surgery is no different.

The VATS lobectomy has been a recent but well-received addition to the expected repertoire of graduates, and Dr. Chadrick Denlinger, associate professor of surgery at the Medical University of South Carolina, Charleston, allows his chief residents to take other trainees through the case, and expects that all new graduates can do one. Across the coast, Dr. Joseph Woo, newly appointed chair of cardiovascular surgery at Stanford, agrees. This expectation alone informs us that our specialty is dynamic and that the definition of an essential skill is in constant flux. On the other hand, cardiac surgery has no touchstone or standard minimally invasive procedure. However, Dr. Woo explains, the ABTS has set its recommendations in anticipation of the continued success of minimally invasive approaches to cardiovascular problems. The board doesn’t require mastery of any specific minimally invasive cardiac operation by the end of a training program, but it does require that we are exposed to a number of different endovascular and nontraditional approaches to coronary, valve, and aortic surgery. Coupled with our presumed mastery of the standard, open operations, we should then have the basic skills necessary to learn whatever minimally invasive operations we like, depending on our interests and our post-training mentorship.

Of course, the safety and efficacy of thoracic aortic stent grafting and minimally invasive mitral surgery have already been proven to some degree, and the operations aren’t going away anytime soon.^3,4 So what is stopping us from learning this stuff during our training? The answer is complicated. Dr. Woo cites the lack of visualization for two surgeons, the difficulty in preventing and controlling technical complications in a limited field, and the very nature the operations themselves.

Take, for example, the minimally invasive mitral valve repair. Its open counterpart requires a skill set that few trainees, if any, can claim mastery of until the very end of their training. The skill required, patient selection, and pathology treated make the operation sort of a "boutique" treatment. The patients that are offered right thoracotomy approach tend to be younger, less symptomatic, and with less complex disease. They have higher expectations. As Dr. Woo put it, "if you perform an absolutely perfect repair, then you’ve only done your job. But there is no way to do any better." With that sort of standard, many attending surgeons are hesitant to hand over the instruments to a trainee. Furthermore, not every resident’s technical ability lines up with what is required of that interest, and more importantly, not every resident is interested. Because of the highly specialized nature of the operation, the relatively smaller patient base, and the technical difficulty involved, it is often up to the highly motivated fellow or resident to gravitate to these repairs and seek out the training on their own.

Dr. James Fann, cofounder of the annual TSDA boot camp and a national surgical education leader, has some perspective on the matter. If residents are interested in gaining added endovascular or minimally invasive skills, he suggests, they first have to prove themselves in the operating room. When they’ve mastered the skills for an open technique and have proven they can get out of trouble, then an attending might feel comfortable letting them take on these more complex cases. It takes a combination of skill and interest – and as only a minority of trainees will have both, most training programs do not require that every TEVAR or mini-mitral be staffed with a resident.

It seems that simulation does not provide an easy shortcut beyond this approach, though it does have a role. To be honest, I expected Dr. Fann to preach the simulation gospel, and tell me about some incredible TEVAR or TAVR simulator he was getting ready to unveil, but his response was far more measured. "The role of simulation," he said, "is not to teach a resident how to operate. It is an adjunct – a tool that can be used to identify and address specific technical issues outside of the operating room." He reinforced the importance of mastering traditional surgical techniques before embarking on miniaturization. Simulation can help trainees operate more efficiently and effectively, but it cannot and should not replace mentored operative experience.

MICS simulation does exist, as anyone who has worked with Dr. L. Wiley Nifong and Dr. Randolph Chitwood’s high-fidelity tissue simulators for minimally invasive mitral valve repair knows. Simbionix USA (Cleveland) has just obtained FDA clearance for its TEVAR simulator that can be tailored to rehearse an upcoming case using a patient’s CT scan. On the lower end of the cost spectrum, a Dutch group and a separate Hannover group have developed low-cost, reproducible models of mini-mitral surgery that can be built from materials from a hardware store.⁵ Again, all of these tools are designed to be adjuncts to experiential training and mentorship, not mentors in and of themselves.

Residents can and should be exposed to TEVAR, TAVR, mini-mitral repair, and other less invasive approaches that are offered at their institution if they are interested. These, along with any other skills beyond traditional open techniques, make the surgeon better. More importantly, they help the trainee gain the basic wire and small incision skills they will need to learn quickly any newly developed operations that the changing specialty requires. They may not master the skills as a resident, but they are that much more prepared to hone those skills with their mentors when that time comes. In fact, the faculty I spoke with placed far more emphasis on mentorship after residency than aggressive residency training, simulation, and superfellowship as the key to gaining these advanced skills. Trainees should be soaking up all of the skills that they possibly can while they can, and if one is smart, ambitious, and skilled enough to become technically proficient at a more technically advanced skill, it certainly makes them a more desirable surgeon. For most of us, however, it is more important to realize that the training never truly ends, to take advantage of the opportunities afforded by residency, and to continue getting those reps in the OR.

References

1. Cardiac Surgery in the Adult, 4e. New York, N.Y.: McGraw-Hill; 2012.

2. J. Thorac. Cardiovasc. Surg. 2012; 144:612-16.

3. Circulation 2013;6:407-16.

4. Ann. Cardiothorac. Surg. 2013;2:744-50.

5. Interact. Cardiovasc. Thorac. Surg. 2013;16:97-101.

In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.

In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.

"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.

He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."

In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.

iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.

Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.

CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.

CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.

SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.

TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.

NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.

CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.

EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.

Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.

This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.

What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.

If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.

Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.

In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.

In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.

"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.

He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."

In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.

iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.

Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.

CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.

CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.

SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.

TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.

NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.

CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.

EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.

Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.

This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.

What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.

If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.

Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.

In nearly every facet of our lives, our mobile devices have taken over. Managing our calendars, organizing our contacts, and planning our driving directions -- our devices have become invaluable and ubiquitously present. While the ease of use of smartphones and tablets puts the power of portable computing in the hands of everyone, mobile software seems to be particularly appreciated by young professionals, who seek the convenience of on-the-go functionality and feel comfortable with computing in the palms of their hands. Throughout the world of education and a breadth of academic fields, advanced software programs have gained momentum, recognized for their ability to provide up-to-date, on-the-ground information.

In recent years, there has been an explosion of new software programs applicable to the field of cardiothoracic surgery, and these applications have been well received by modern trainees.

"Mobile apps are incredibly convenient because they provide a means of accessing information while on the go," states Jonathan Spicer, a thoracic trainee at M.D. Anderson Cancer Center in Houston.

He continues, "Having the capacity to look up helpful information from my phone while in the operating room, on the ward, or in transit is particularly helpful."

In this article, we aim to highlight some of the more exciting and innovative mobile software programs available today for those interested in expanding their knowledge in cardiothoracic surgery or looking for an easy-to-access resource.

iBronch (Edward Bender), $0.99: iBronch is one of the many outstanding thoracic surgical apps developed by Ed Bender. This program aims to guide learners through the basic anatomy of the trachea and bronchial tree, with correlation of simultaneous images from a fiberoptic bronchoscope and along an anatomic airway diagram. Branches of the pulmonary tree are labeled on the schematic and the bronchoscopy images. This app is particularly useful for those trainees gaining comfort with bronchoscopic procedures; however, its utility may be less significant for more advanced learners. Regardless, this is a great program, quite helpful for the intended audience.

Thoracic Lymph Node Map (RADIOLOGiQ, LLC), Free: This app provides a color-coded lymph node map, associated with computed tomography images and adapted from the International Association for the Study of Lung Cancer (IASLC) lung cancer project. This program provides excellent illustrations of the anatomic definitions for each of the intrathoracic lymph node stations. This is helpful both in examining imaging studies of actual patients and in the operating room.

CT Journals (Edward Bender), Free: This software program serves as a scholarly journal aggregator for the field of cardiothoracic surgery. The app displays feeds for journals of interest, with inclusion of those relevant periodicals with the most readership and highest impact factors. Not only can one access the articles while online, abstracts can be saved for future use offline. This is a great resource, but users should be aware that access to the full articles is available only for those who have active accounts providing them access to the specific journals.

CTSNetWiki (Edward Bender), Free: Cardiothoracic Surgery Notes is an online review developed and maintained by residents in thoracic surgical training. This resource is a tremendous repository of information, compiling graphics, text, and other multimedia content on a breadth of topics. This app allows general review of a wide variety of cardiothoracic surgical problems and is appropriate for both the novice learner and as a review for those who are further along in their training.

SESATS IX (Edward Bender), Free: Perhaps the most valuable mobile software application out there, the Self Education Self Assessment in Thoracic Surgery (SESATS) IX application contains actual questions from previous versions of the SESATS. The mobile app even includes the associated images, videos, and CT scans that correspond with the questions. Although the program does not contain the latest version of SESATS, the utility of this app cannot be overestimated. This program is enormously helpful for self-testing, on-the-go topic-specific learning, and exam preparation. This is a real gem of a find, and it comes with a strong recommendation to all trainees for its download and use.

TSRA Primer of Cardiothoracic Surgery (Thoracic Surgery Residents' Association), $4.99: Produced by CT residents for CT residents, this is probably the most useful resource for the intern, junior resident, or new fellow who needs to brush up on the basics before rounds, in between consults, and before assisting in the OR. It's not comprehensive, but it is full of clinical pearls covering all the major divisions of cardiothoracic surgery. Many cardiac residents, especially younger integrated residents, have been waiting for a straightforward, practical tutorial like this for years. Beautiful and often interactive illustrations and videos really make this iBook memorable.

NCCN Guidelines (TIP Medical Communications), Free: Available for Android and iOS, this compendium of NCCN guidelines for 56 cancers and cancer-related topics is indispensible for trainees. The utility of having up-to-date, in-depth guidelines for diagnosis and staging of all commonly encountered malignancies cannot be overstated. Additional topics ranging from management of cancer-related emesis to lung cancer screening guidelines polish it off. A must have for anyone who treats cancer, not just thoracic surgeons.

CathSource (ECGSource, LLC), $3.99: Available for Android and iOS, CathSource is a mobile app that aims to teach cardiovascular medicine fellows about coronary anatomy, angiogram projections, and catheter-based hemodynamic measurements. Luckily, CT trainees stand to benefit from the app as well. It seems to be most helpful for learning coronary anatomy on the different projections, but it also has exhaustive hemodynamic formulae and tracings for more detailed review. The app has over 30 videos of normal and abnormal findings.

EchoSource (ECGSource, LLC), $4.99:It's the same idea as above, but -- you guessed it -- for echocardiography. Both are good tools, especially for residents who teach. Both apps take simple, conceptual drawings to start and expand them with real imaging. Residents who have spent a good deal of time in learning cath and echo may find these apps less useful.

Pocket Heart (PocketAnatomy), $9.99: This is an interactive, 3D heart model with a fairly detailed presentation of cardiac anatomy and added features such as pinning quizzes and case studies. While cardiothoracic residents ought to have the anatomy down, the app can be used to teach patients and families about various anatomical aspects of cardiac disease. The graphics leave a little to be desired, but anyone who teaches medical students or patients frequently will enjoy having this easy-to-understand tool handy.

This list of cardiothoracic-specific mobile applications is by no means exhaustive. Each physician's needs will be different, and the options are countless. Countless risk calculators, mnemonic databases, formula compendiums, and pharmacologic formularies clutter the app store. Note-taking suites such as OneNote and Evernote (personal favorite of both of the authors) can help turn the most hare-brained resident into a paragon of organizational excellence. Journal citation managers such as EndNote, Dropbox, Mendeley, and Yep can help organize and manage that virtual pile of unread but probably important journal articles that keeps building up in your inbox. Even the humble iBooks app can be used to read and mark up pdf files on the fly, all while syncing with your library on your home computer. Many hospital EMRs have mobile platforms with various levels of functionality for tablets and smartphones.

What is obvious is that mobile computing technology is rapidly changing medicine and surgery in many ways. Although each one of us strives to be a complete physician, utterly self-reliant and assured of one's clinical knowledge, we all must learn the basics first. Whether at the bus stop, in a resident lounge, or in the operating room, these mobile technologies help us to learn more efficiently while on the go.

If there are any gems we have forgotten to highlight, please send an e-mail to Thoracic Surgery News and we will try to present them in the future. We hope that the residents reading this column can find a new app they didn't know they needed, one that will energize them and push their learning to a new height. Just don't forget to look up once in a while.

Dr. Antonoff is a 2nd-year, Thoracic-track trainee at Washington University in St Louis. Dr. Zeigler is a 3rd-year, integrated Cardiothoracic Surgery trainee at Stanford (Calif.) University. They reported no relevant financial conflicts.