Thoracic surgery in a crisis

New report outlines dire shortage of thoracic surgeons

In the United Kingdom all specialties and primary care are calling out for more doctors. The government's response has been to open more medical schools and increase the places in existing schools. Clearly this will not address today's problems and the numbers may be too small to address tomorrow's. One response should be for us all to examine whether we currently deliver care in the most effective manner. Some specialties have been more innovative than others in sharing the workload with nursing colleagues, but a shortage of nurses means that this is only a partial solution. Making patients more equal partners and enhancing their ability to care more for themselves is another approach, but is applicable only to certain aspects of care.

The recent report from a joint working party of the British Thoracic Society and the Society of Cardiothoracic Surgeons of Great Britain and Ireland suggests that thoracic surgery especially deserves an increase in numbers.1 Possibly this specialty may have been neglected in the same way that respiratory medicine appears to have been. Respiratory disease kills one in four people in the United Kingdom—nearly twice the average for the European Union. Within Europe, only Kyrgyzstan, Kazakhstan, Turkmenistan, Uzbekistan, and Ireland have higher mortality from respiratory illnesses than the United Kingdom. Morbidity imposes a similar burden, and respiratory illness is the most common illness responsible for emergency admissions to hospital. Respiratory diseases cost the National Health Service £2576m in 2000.

Given these figures one might imagine that tackling respiratory illness would be a government priority. Priority in the national service frameworks introduced by the government is given, however, to heart disease, cancer, diabetes, renal disease, chronic—mainly neuromuscular—conditions, children, and the elderly. The absence of a specific national service framework for respiratory illnesses seems a strange omission. Setting priorities in this way may also create unexpected pressures. For example, in the management of lung cancer the same surgeons who are being pressurised to deliver results in coronary artery bypass surgery are also being asked to provide prompt surgery for lung cancer. As the report makes clear, we may be doing particularly badly in the United Kingdom in this respect.1

Each year 40 000 new cases of lung cancer are diagnosed in the United Kingdom. The best chance of cure lies with successful surgical resection. Less than 10% of patients with lung cancer in the United Kingdom have lung resections. How far this reflects advanced disease at presentation, comorbidity, an elderly population, a nihilistic approach to lung cancer, or lack of resources is unclear. However, resection rates of 24% and 25% have been reported in Dutch2 and American3 patients. This must make us concerned that the low figure for resections in the United Kingdom in some way reflects pressures on the service. Faced by competing demands from a waiting list for coronary artery surgery one must worry that reasons such as a “touch of comorbidity,” “being a bit old,” or “tumour being a bit near the midline” might be subconsciously influencing decisions regarding operability.

One solution to the problem of competing demands involves separating resources (for example, designated operating time for thoracic surgery) and enhancing the specialty of thoracic—as opposed to cardiothoracic surgery. Relying on cardiothoracic surgeons to do lung resections may also mean that some do too few to maintain competence and five year survival figures are better in those who operate more often.4

The need for specialist thoracic surgeons is emphasised by the fact that surgery for lung cancer represents less than half the workload of the 40 purely thoracic surgeons in the United Kingdom. Surgical management of pneumothoraces, empyema, mediastinal masses, and benign and malignant conditions of the oesophagus; lung biopsies; and lung volume reduction surgery all need expertise that justifies a specialist approach. Different skills and attributes are needed in thoracic as opposed to cardiac surgery.

Patients with respiratory disorders who need thoracic surgery, and the physicians who care for them, are grateful for the help they receive from hard pressed cardiothoracic surgeons. However, the time has now come to double the number of purely thoracic surgeons in the United Kingdom by welcoming more from overseas, retraining surgeons experienced in other surgical specialties, and enhancing the number and quality of training opportunities to entice the young into this specialty. The rest of us may be desperate for more colleagues, but the supply is limited. We should look at delivering care in different ways so that the limited number of doctors can be targeted at specialties such as thoracic surgery, where the need is desperate.