1. The Bright Future of Cardiothoracic Surgery in the Era of Changing Health Care Delivery: An Update 
Frederick L. Grover, MD 
The Annals of Thoracic Surgery 
Volume 85, Issue 1, Pages 8-24 (January 2008)
DOI: /j.athoracsur
Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
Change in graduate medical education (GME) positions filled by United States medical doctors from 1998 to 2004 is shown with a decrease in cardiothoracic surgery along with four other specialties. Note however, the marked increase in anesthesiology after the period of the mid-1990s when they experienced difficulty in filling their positions, which resulted in a shortfall of anesthesiologists. (CT = cardiothoracic; GI = gastrointestinal; IM = internal medicine.) (National GME Census [American Association of Medical Colleges and American Medical Association]. © 2007 Association of American Medical Colleges. All Rights Reserved. Reproduced with permission.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
Applicants to thoracic surgery resident programs, 1993 to Note the decrease in total (circles) and United States medical graduate applicants (triangles) for thoracic surgery resident programs during the past 3 years compared with active positions available (squares). Only 91 of 126 positions filled for this past year for residents beginning in July (From National Residents Matching Program (NMRP), Results and Data Main Residency Match, 1990–2005, reprinted with permission.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
Number of active thoracic surgeons, 1990 to This graph demonstrates a decrease in active cardiothoracic surgeons during the past 2 years, decreasing from approximately 5100 to just slightly over (American Medical Association Masterfile, 2006 includes physicians self-designating as cardiovascular surgery, cardiothoracic surgery, and thoracic surgery.) (© 2007 Association of American Medical Colleges. All Rights Reserved. Reproduced with permission.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
Age distribution of cardiothoracic surgeons shows those who are in clinical practice (black), nonclinical practice (white), and those who are residents (gray). This graph from the American Association of Medical Colleges Committee on Workforce for Cardiothoracic Surgery demonstrates the large number practicing cardiothoracic surgeons older than 55 years and even older than 65. (American Medical Association Masterfile. January 1, American Medical Association.) (© 2007 Association of American Medical Colleges. All Rights Reserved. Reproduced with permission.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

6. Fig 5
An additional 3000 surgeons will be needed if thoracic surgery residents fall to 75 per year (triangles). Note the shortfall of 3000 surgeons by 2025 if only 75 residents per year are matched into thoracic surgery residency programs. (Baseline demand, dashed line.) (A Grover, American Association of Medical Colleges Workforce Analysis for Cardiothoracic Surgery, personal communication, 2007.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

7. Fig 6
Workforce anesthesiology positions filled by using the National Resident Matching Program (NRMP) during the years 1990 to Note the decrease in recruitment of anesthesiology residents during the mid-1990s compared with all residents (dark gray), with a 4-year consecutive decrease in resident matching and the 6-year recovery period. (CA-1 = clinical anesthesia level 1, medium gray; PG-1, postgraduate year, light gray.) (From National Residents Matching Program (NMRP), Results and Data Main Residency Match, 1990–2005, reprinted with permission.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

8. Fig 7
Adjusted survival in patients with percutaneous coronary intervention (PCI; black line) with bare-metal stents vs coronary artery bypass grafting (CABG; gray line). This graph demonstrates a significant survival advantage of patients who had high severity coronary artery disease treated with CABG compared with stents at Duke University from 1996 to (Smith PK. Relative merits and clinical selection of CABG, bare metal stents, and drug eluting stents in practice and in evolution. Testimony before the US Food and Drug Administration, Circulatory System Devices Advisory Panel, December 8, 2006.)
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9. Fig 8
The New York State data from 1997 to 2000 for 3-vessel coronary artery disease (N = 23,022) is very similar to the Duke data in Fig 7 that demonstrates a significant survival advantage for patients treated with coronary bypass (CABG, grey line) compared with stents (black line) at 3 years. (From Hannan EL, Racz MJ, Walford G, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med 2005;352:2174–83. Copyright © 2005 Massachusetts Medical Society. All rights reserved.)
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10. Fig 9
Medicare payment trend for coronary artery bypass graft procedures in real dollars (triangles) and dollars adjusted to the Consumer Price Index (CPI; squares). The marked reduction in reimbursement both in real dollars) in inflationary-adjusted dollars for Medicare reimbursement for coronary bypass for patients is demonstrated over the past 10 years. (Medicare data from the Physician Fee Schedule.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

11. Fig 10
The total cost by hospital for coronary artery bypass grafting (CABG) procedures in the Virginia Demonstration Project as well as the observed-to-expected mortality ratios. Of interest is that the hospitals with the lowest observed outcome/expected outcome (O/E) ratios (ie, the best outcome) have the lowest cost. (VCSQI, Virginia Cardiac Surgery Quality Initiative (Rich, Jeffrey B; March 15, 2005, Testimony before the U.S. House of Representatives, Committee on Ways and Means.)
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12. Fig 11
Cost-savings are possible from improvements. The incremental cost of various complications is demonstrated compared with the cost of patients with no complications. This shows the tremendous impact of morbidity on hospital costs. (Rich, Jeffrey B; March 15, 2005, Testimony before the U.S. House of Representatives, Committee on Ways and Means.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

13. Fig 12
The Relative Value Update Committee (RUC) recommended intraservice work per unit of time (IWPUT) values (diamonds) for various adult cardiac and general thoracic surgical codes are shown compared with the original proposed Centers for Medicare & Medicaid Services (CMS) values (squares), which were much lower. Fortunately, CMS reversed its position and agreed to the RUC recommendation for reimbursement. (Department of Health and Human Services Centers for Medicare & Medicaid Services CMS-1512-PN RIN 0938-A022 Medicare Program: Five-year Review of Work Relative Value Units Under the Physician Fee Schedule and Proposed Changes to the Practice Expense Methodology.)
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14. Fig 13
Observed-to-expected ratio for all isolated coronary artery bypass graft patients (CABG) from 1990 to Graph shows the results of logistic modeling for patient risk. The change over the decade is statistically significant, with p < for time trend ( ). Note the very significant decrease in observed-to-expected mortality ratios for CABG patients for the decade of the 1990s.
The Annals of Thoracic Surgery  , 8-24DOI: ( /j.athoracsur )
Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

15. Fig 14
Observed-to-expected ratio for all isolated coronary artery bypass grafting (CABG) patients from 2000 to 2005 (p < for time trend). Graph shows results of logistic modeling, adjusting for patient risk. Note a similar reduction in observed-to-expected mortality ratios for CABG patients during the first 5 years of this century.
The Annals of Thoracic Surgery  , 8-24DOI: ( /j.athoracsur )
Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

16. Fig 15
The 2006 election cycle political action committee (PAC) receipts through November 27, 2006, are noted for various groups. Note that the trial lawyers raised $6 million vs The Society of Thoracic Surgeons’ (STS) $377,000 ( (AMA = American Medical Association.)
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Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

17. Fig 16
The 2006 breakdown of receipts of contributors (clear slice) vs noncontributors (grey slice) to the political action committee (PAC). Of major concern to The Society of Thoracic Surgeons is that only 14% of our members contribute to the PAC fund. This is not acceptable, and we must do better to have a major impact on health care policy. (STS Political Action Committee.)
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18. The Annals of Thoracic Surgery 2008 85, 8-24DOI: (10. 1016/j
The Annals of Thoracic Surgery  , 8-24DOI: ( /j.athoracsur )
Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions