COOPERATION BETWEEN THE CARDIOLOGIST AND THE CARDIAC SURGEON

\mile patients with heart disease are frequently treated by cardiologists, more and more of them will eventually be referred to cardiac surgeons. Theoretically, there should be a smooth referral procedure where each party contributes effort, knowledge and skill in order to achieve the overall goal of the patient’s recovery and well-being. Unfortunately, this is not always the case. In many instances, the cardiologist traditionally performs the initial workup: physical examination, el$ctrocardiogram, echocardiogram, cardiac catheterization, etc; When there is a decision to perform cardiac surgery, the patient is transferred to another department. This department is the cardiac surgeon’s turf. Here, the surgeon gives orders and the cardiologist’s service is no longer desired. At this point, many surgeons feel that the cardiologist has nothing to offer: he or she obviously does not operate, the pre-, intraand postoperative care is the specialty of the surgeon and the cardiac surgeon feels that he or she knows all the cardiology required to handle these patients and does not need additional help. This “macho” approach is supported in some countries by the economics of medicine. With the global fee method now penetrating American medicine, the expenses of the participating cardiologist in the operated patient’s care may be paid from the surgeon’s pocket. The cardiologist may now, so some surgeons feel, not only threaten the surgeon’s authority, but also his or her income. Many cardiologists are appalled by what they call surgical possessiveness and aggressiveness. They are also fighting for their ego and want to stay in charge of their patients. The results are frequently conflicting orders, delays in procedures, longer hospital stay and confusion among housestaff, nurses, patients, and their families. The technology, sophistication, and complexity of both cardiac surgery and cardiology are dramatically increasing. There is a huge body of growing clinical, practical experience and newer modalities in diagnosis Cfor example transesophageal echocardiography and intravascular imaging), and of treatment (interventional cardiology and ablation therapy) which require very specific and long training. There is no single cardiac surgeon (andprobably not a singlecardiologist) who can possess state of the art skills in each technology. However, these skills cannot be ignored. A good echocardiographer in the operating room during mitral valve repair may save the patient from the possibility of going to the recovery room with severe mitral regurgitation. A good electrophysiologist in the operating room during arrhythmia surgery is frequently the difference between failure and success. In fact, in many good institutions, there are direct communication lines both by intercom and fiber optic cabling that literally connect the cardiologists to the surgeon in the operating room. Depriving the patient of the experience of a cardiologist or of a cardiac surgeon, and of the technologies they can offer, may decrease the quality of care and hurt the patient. Here at New York University 0 Medical Center, these problems were identified and resolved by direct confrontation and discussion. A special reengineering cardiovascular team had the cardiologist/cardiac surgeon conflict high on their agenda. After many meetings and discussions, some problems have not yet been solved and others are still pending and are being discussed. However, by now everyone has realized that if he is not a part of the solution, he is a part of the problem. For the time being, the net results are: