Sacrificing the Future for the Sake of the Present

Although ligation of a patent ductus arteriosus was first reported in 1938,1 the first palliative congenital heart surgery might be said to have been undertaken on November 29, 1944, when Eileen Saxon received the first systemic-to-pulmonary artery shunt at the hand of Alfred Blalock.2 The surgery was a technical success, but it was a particularly high-risk endeavor necessitating Vivien Thomas’ direct supervision over Dr. Blalock's inexperienced hands. Subsequently, intrepid surgeons ventured to change the outcomes of children with congenital heart disease by daring greatly and devising procedures to address increasingly complex anatomical diagnoses. C. Walt Lillihei pioneered cross-circulation and dared to undertake intracardiac surgery to close ventricular septal defects and palliate tetralogy of Fallot.3 Around the same time, John Gibbon ushered in the era of cardiopulmonary bypass when he used it during a procedure to close an atrial septal defect in an 18-year-old woman.3 Soon thereafter in 1957, Ake Senning developed an intracardiac baffle to palliate d-transposition of the great arteries.4 Innovation was iterative through the 1960s and 1970s: Senning's procedure gives way to Mustard's procedure, one whose days were numbered when Jatene reported the arterial switch operation in 1976.4 That era was replete with continued advancements as the likes of Rastelli,5 Fontan,4 and Norwood6 pushed things further forward. The field progressed onward as the priority began to shift to correcting, rather than palliating, congenital heart disease, and Aldo Castaneda championed deep hypothermic circulatory arrest to enable primary neonatal and infant congenital heart surgery.4 Most recently, in the 1990s, the field continued to advance as high-risk procedural approaches were refined for patients with single ventricle anatomy. This lineage of advancements in survival have largely been attributable to perseverance in the face of failure in spite of and, importantly, because of risk. Similar to other surgical specialties, but perhaps more profoundly underscored, the story of congenital heart surgery is founded on risk-taking innovation. During moments when the risk of doing nothing was intolerable, the substantial risks of innovative congenital heart surgeries were willingly undertaken by pioneering patients, surgeons, and families. In those moments of risk and daring greatly, surgeons’ skills were refined, and the risk of future operative mortality was subsequently decreased. Better outcomes were built on improving or honing—that is learning—better operative skills in the crucible of the surgical theater. Incremental success is predicated on experience and mastery of a host of operative procedures. The environment allowing a surgeon and the healthcare team to gain the requisite experience and mastery are increasingly unpermitted. The landscape of congenital heart disease and surgery has reached a self-defining zenith. Exceptional results are now expected. Congenital heart programs prioritize volume to safeguard quality among other metrics.7 Those results, now parsed to include not only survival, but also other factors such as neurocognitive outcomes, hospital length of stay, and surgical complications, are intimately integrated into a hospital's reputation. The expectation of exceptional results has translated to public reporting and ranking systems such as the US News and World Report Best Children's Hospitals National Ranking (USNWR). Consequently, hospitals are increasingly faced with pressures to attain a high ranking and redefine their relationship with risk. The existing system by which risk for a given patient or patient population is codified and adjusted has multiple shortcomings, all of which have significant impacts on the metrics by which hospitals and programs are being assessed. As has been elegantly detailed by Dr. Richard Jonas recently, the current system of risk stratification based on postoperative, early mortality is inherently flawed.8 This methodology, used by both USNWR and the Society for Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD), not only does not account for the differences in surgical management strategies with regard to early palliation versus complete repair, but it also favors those programs with a worse longer term mortality who take a much more conservative, multistage approach to management. As Dr. Jonas correctly points out, this cannot be accounted for with an early mortality risk-adjustment strategy. In addition, the models used by STS-CHSD to estimate mortality risk, and subsequently the USNWR rankings centered on the results of them, are based primarily on the primary procedure of a given hospitalization. This methodology incentivizes the use of single-hospitalization, staged palliative procedures and hybrid approaches, especially for benchmark conditions such as hypoplastic left heart syndrome. As such, for certain programs seeking to increase their ranking within STS-CHSD and USNWR, moving toward a short-term risk-averse model with potentially worse overall mortality can be rewarding. THE ECONOMICS OF DECISION-MAKING As a result of desiring to attain a high ranking, it should be expected that hospitals will develop increasing levels of risk aversion as high rankings are achieved. Risk aversion is the preference of a riskless prospect (eg, not dying as a result of a surgical procedure not performed) to a risky one (eg, surviving as a result of undergoing a surgical procedure) of equal or greater expected value.9 In what is known as “the gambler's fallacy,” when a choice is made between a risky and a safe option immediately after experiencing a loss, there is a higher likelihood for riskier behavior. Conversely, risk aversion increases after experiencing a gain.10 Taken in the context of an organization, this suggests that the more successful a program becomes, the higher the likelihood for risk aversion. In this context, risk aversion means decreasing the risk of a suboptimal outcome that may come from either performing an operation on a medically complex, high-risk patient or from allowing a less experienced surgeon to perform a semicomplex procedure. Burack et al have previously shown the negative impact public reporting has on the likelihood of denial of surgical treatment to high-risk patients.11 This economy of ranking-based decision-making has been warned against by Spray and Gaynor who said, “We must be very careful that we don’t create a system where we are afraid to take on a patient with increased risk of mortality because it may affect our overall ranking.”7 Although those and other authors were writing primarily regarding individual cases, to our knowledge, no one has recognized the much farther-reaching negative impact that preserving a ranking could affect on the development of a trainee or less experienced surgeon. In those cases, the impact is on a given surgeon's capabilities across his/her entire career, something that would surely influence the care and outcome of hundreds of patients per each affected surgeon. The economy of risk and return is fundamental to financial theory, with investors expecting higher returns for taking on increasing risk. For a significant increase in risk to be undertaken, the expected return must be significantly increased as well. If a hospital has achieved a high ranking, there is likely negligible return, as it pertains to their ranking, from taking on higher levels of risk. Furthermore, within the context of congenital heart surgery, there is essentially no return for an institution, save only the possibility of future surgical success, when the relatively higher risk of allowing a trainee to operate is undertaken. As such, the situation favors risk aversion and avoidance of operations by the inexperienced surgical trainee or even junior faculty member. Thus, from a behavioral science standpoint, we have created a system that will increasingly favor risk aversion. As hospitals become more risk averse, the training and capabilities of congenital heart surgeons, as well as other physicians and surgeons, will be negatively impacted because opportunities to perform complex surgeries will be reserved only for the most experienced surgeons. As a result, once those surgeons retire who once had the opportunity to dare greatly and to learn in the operating room by undertaking complex cases they had to sometimes figure out in the moment, our field will be lacking in the surgical expertise to continue providing the best congenital heart care to our patients. When such an eventuality is coupled with the increasing rate of premature births,12 one of the most important risk factors for operative mortality13 and one associated with increased congenital heart disease complexity,14 we are certain to see worse outcomes. In that, our field, which was built on daring greatly and pushing the boundaries of surgical and medical capabilities, will likely enter a senescent phase, will see the hands of time turned back to a less successful era, and our future outcomes will not be what they have been.