SIDHU P. GANGADHARAN, MD Chief, Division of Thoracic Surgery and Interventional Pulmonology BETH ISRAEL DEACONESS MEDICAL CENTER BOSTON, MA W HO SHOULD.

SIDHU P. GANGADHARAN, MDChief, Division of Thoracic Surgery and Interventional

Pulmonology

BETH ISRAEL DEACONESS MEDICAL CENTERBOSTON, MA

WHO SHOULD BE RESPONSIBLE FOR THE INITIAL

DIAGNOSIS AND STAGING OF LUNG CANCER?

NON-SURGEONS

SIDHU P. GANGADHARAN, MDChief, Division of Thoracic Surgery and Interventional

Pulmonology

BETH ISRAEL DEACONESS MEDICAL CENTERBOSTON, MA

WHO SHOULD BE RESPONSIBLE FOR THE INITIAL

DIAGNOSIS AND STAGING OF LUNG CANCER?

NON-SURGEONS

NOT ONLY

Outline of arguments

• Expertise

• Finances

Venn diagrams

Venn diagrams

Harvard graduates

US Presidents

Venn diagrams

Plays that score

touchdowns on second and goal

from the 2 yard line

Safe plays

Run plays

Wilson to Lockette,

INT by Butler

Venn diagrams

Surgeons Only Include Non-surgeons

Interventional pulmonology

RadiologyGeneral

practioner

GI

Moving beyond wars of turf

• Control of work-up

• Control of treatmentIssues of expertise

Specter of cardiac

angiography• Ownership argument

• Slippery slope

argument

• Technique argument

Control of work-up

Multidisciplinary cancer care

Ownership of the lung

cancer patient

Bjegovich-Weidman M. J Oncol Pract. 2010 Nov;6(6):e27-30.

Should surgeons do

brain biopsies?

Diagnosis of advanced

cancer

Jemal A. CA Cancer J Clin 2010;60:277-300.

Performance profile of

biopsy• Low yield FNA

Early stage lesions

Shimizu K. Lung Cancer 2006;51:173–179.

Performance profile of

biopsy

Early stage lesions

Shimizu K. Lung Cancer 2006;51:173–179.

Hammer/nail does not apply

• Ownership is linked to

treatment, not work-up

• Many patients present

with advanced disease

not requiring

interventional work-up

• Many patients with early

stage only managed by

surgeon

• Multidisciplinary team

approach logical

Ownership

Will surgical treatment

decline?

• Staging and diagnosis

already encompasses

multiple non-surgical areas

• Clear line between work-up

and treatment

• Adapt with technology (vascular

vs. cardiac)

• Rules of engagement are

crucial• Radiation oncology• Endobronchial therapy

• Not unique to AMC

Slippery slope

considerations

Who does it better?

• Learning curve

Technique

Hu Y. J Thorac Cardiovasc Surg 2013;146:1387-92

Stather M. Respirology (2015) 20, 333–339

Who does it better?

• Limited numbers in

general practice

• BIDMC

• 400 EBUS FY2014

• 75% lung cancer

staging/dx

Technique

Hu Y. J Thorac Cardiovasc Surg 2013;146:1387-92

Stather M. Respirology (2015) 20, 333–339

Is the pie big enough to

share?• Impact on individual

P/L

• Impact on

institutional bottom

line

Issues of finances

EBUS contributes to medical center

bottom line

• $24,742/NP EBUS referral

• $19,174 technical fee/NP EBUS

Downstream revenue

Pastis N. CHEST 2012;141(2):506-512

EBUS contributes to medical center

bottom line

• Technical fee per EBUS much

lower

• High volume tertiary care

setting results may not be

transferable

• Assumption about EBUS

driving NP volume

Weakness of argument

Thoracic surgery contributes to

hospital bottom line

Contribution

margin/wRVU

Resnick A. Ann Surg 2005;242: 530–539

Thoracic surgery contributes to

hospital bottom line

Margin higher without

diagnostic/staging

procedures

• BIDMC contribution

margin TS >IP

• wRVU/case 4-5x more

McKenna R. Ann Thorac Surg 2007;84:1663-1668

Summary

• Intake and treatment

determines ownership

• Responsibility is not exclusive

• Many diagnostic/staging

procedures logically done by non-

surgeons

• Many patients undergo

diagnostic/staging at the time up

upfront resection

• Fear of loss of treatment

authority mitigated by

multidisciplinary care

• Increased surgeon profitability

with higher proportion of

procedures that non-surgeons

cannot do

Why non-surgeons

should have

responsibility for

diagnosis and staging

THANK YOU

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