Current status of young cardiac surgeons in Japan

ISMICS International Fellows and Residents Luncheon, June 4 2009, 09 ISMICS San Francisco

Current status of young cardiac surgeons Current status of young cardiac surgeons in Japanin Japan

Kan Nawata

Naoto Miyagi, Hiroo Takayama, Shin Takabayashi

JAYCS: Japanese Association of Young Cardiac Surgeons


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10000

20000

30000

40000

50000

60000

'86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06

Other

Aneurysm

IHD

Valve

Congental

Cardiovascular Surgery in JapanCardiovascular Surgery in JapanAnnual report by the Japanese Association for Thoracic SurgeryAnnual report by the Japanese Association for Thoracic Surgery

Calendar Year

Number of Cases


The number of Japanese CV surgeonsThe number of Japanese CV surgeons

• Certificated by the Japanese Board of Cardiovascular Surgerythe Japanese Board of Cardiovascular Surgery

(since Jan. 2002)

• 316 Main Hospitals (>100 cases per year)• 127 Satellite Hospitals (>50 cases per year)

• Approx. 2,000 certificated cardiovascular surgeons

(including vascular surgeons)

+ More than 1,000 uncertified CV surgeons !


Why so many CV surgeons in Japan?Why so many CV surgeons in Japan?

• No regulation about the whole number of CV surgeons in Japan

• Many hospitals where cardiac and aortic surgeries are performed– No regulation regarding opening a new cardiovascular surgery

program in Japan– Better accessibility from the patients’ viewpoint

• Fewer co-medical professionals– No Physician Assistants– Postoperative management by young CV surgeons– Endless miscellaneous duties


Unsolved issues in Japan #1: Unsolved issues in Japan #1: RegionalizatonRegionalizaton

• Because of no regulation regarding opening a new cardiovascular surgery program in Japan,

non-high quality low volume programs exist in large numbers

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0.00 100.00 200.00 300.00

CABG年間平均症例数

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0.05

0.10

0.15

0.20

CABG

死亡

率

　　　 Hospital annual CABG volume

mo

rtality rate


6

percent

Surgeons have routine miscellaneous duties 47.3 %Surgeons routinely have over 32-hour labor 96.1 %No preferential pay for cardiac surgeons 94.6 %

↓These conditions are unfavorable not only for cardiac surgeons but also for patients who receive medical care

• Status of working conditions regarding Japanese CV surgeons

(by questionnaires)

Unsolved issues in Japan #2: Status of LaborUnsolved issues in Japan #2: Status of Labor


• Non-high quality low volume programs in some hospitals• Consultant surgeons who are still eager to operate by themselves• Long training at the bottom of the heap• Relatively low income• Uncertainty over their career path

• A considerable number of Japanese CV surgeons go abroad for more clinical experience.

• Is it acceptable as one of the developed countries?

Young CV surgeons in Japan confrontYoung CV surgeons in Japan confront


On the other hand,On the other hand,


How are the operative outcomes?How are the operative outcomes?

• Good operative outcomes for the smaller number of cases experienced per year

JTCVS 2008;135:1306-12

Japan SCORE


10

No. of Pts 1780 6530 9419 9479 9858 6227 7494 6267 3411 49311721

5

No. of Hsp

87 105 94 68 55 28 29 21 10 13 30

Unadjusted 30-day mortality rates Unadjusted 30-day mortality rates by CABG procedural volume in Japanby CABG procedural volume in Japan

In Japan, all categories over 41 CABG procedures per year were 30-day mortality rates under 2.0%

Number of Isolated CABG Admissions


JTCVS 2008 Jun;135(6):1202-9

Risk-adjusted 30-day mortality rates Risk-adjusted 30-day mortality rates by CABG procedural volume in United Statesby CABG procedural volume in United States


Expert Commentary for Expert Commentary for Japanese Cardiovascular SurgeryJapanese Cardiovascular Surgery

• Given the consistently low volume of most Japanese CABG programs, their overall results will come as a surprise to many.

• Perhaps there are lessons from this extreme example that might be applicable to less extreme but smaller programs in other countries.

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JTCVS 2008 Jun;135(6):1202-9


How are the operative outcomes?How are the operative outcomes?

• Good operative outcomes for the smaller number of cases experienced per year

• Detailed operative records with schemas• Pre- and post-operative discussions

(with cardiologists, nurses and anesthetists)• Postoperative management by CV surgeons

Learn much from views and discussions

in spite of less opportunity as the operator


Discussion tool for high risk cardiovascular surgeriesDiscussion tool for high risk cardiovascular surgeries


Advantage of Japan

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• Surgeons’ collaboration in operating room• Communication style in conference• Operation records using drawing schemas

• Personalized patient management (by dedicated young CV surgeons)

• Inexpensive insurance for medical malpractice

• Easy access to cardiovascular surgeries• Health-insurance system that covers all of its citizens


However,However,


Young Japanese CV surgeonsYoung Japanese CV surgeons

• Are not satisfied with the current status in Japan

– Need to share the technical tips and pitfalls

– Want to share information about the international status of the same professionals

– Are eager for more opportunities of clinical practice as the operator, not as the intensivists

– Want a little better work-life balance, if possible

Inspired by the last ISMICS International Fellow and Residents Meeting, three young Japanese CV surgeons took the gloves off for

‘INNOVATION’.

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Current status of young cardiac surgeons in Japan