Letter from the Editor

On Strategy

The theme of this issue is “Strategies in Cardiac and Thoracic Surgery”. Stemming from the Greek “strategos” for commander, the term strategy is frequently associated with military operations, and first and foremost the German officer and author Carl Philipp Gottlieb von Clausewitz springs to mind [1], [2]. A more general definition of strategy would be: a planned, anticipating intention to reach a goal, taking into account the available resources. Or, in the more straightforward words of the consulting business, “Strategy is an integrated set of choices that positions a firm to win” [3]. In our economy-driven world, a successful corporate strategy seems to be the guarantor to gain long-term advantage over competitors. The Boston Consulting Group (BCG), a globally acting management consulting firm, calls itself the “world's leading advisor on business strategy” [4]. It even founded a Strategy Institute which is editing a continuous series of publications investigating the various aspects of that arcane term (for instance: [5]). How does this affect cardiothoracic surgeons?

Just as it is a plain fact that life is full of difficult decisions, it should be equally understood that the right strategy will help to make the better ones, thus improving surgical results. Our feature articles in this issue try to provide answers to many tricky questions: Should one treat diseases of the thyroid gland and the heart concomitantly? Can we foresee how good an arterial revascularization procedure will really be? How should we decide upon vascular access for ECMO? What is going to happen to the increasing number of HIT patients? How should we approach awkward tumors in the mediastinum? Can we make intimidating masses shrink? Although we do have an impressive technical armamentarium at our disposal, it will always be true in surgery that at least half of the guarantee for success depends on the right indication – what to do to whom and how – that is: strategy. In the words of the strategy consultant [3]: the surgeon makes a choice, avoiding others, based on a (hopefully) data-driven process and deploys his resources towards this action (technique) in the firm belief that he will gain a sustainable advantage for his patient. The important words here are “data-driven”, “resources”, and “sustainable”.

Apart from individual (operative) strategies there is also a much more common meta-level, sometimes determining treatment principles in general and often motivated politically. Although having been one of the pillars of thoracic surgery for decades, operations on the esophagus have gradually been moved to the hands of abdominal or general surgeons in many institutions throughout Germany. The reasons may lie in changes of surgical training, in the development of more complex gastrointestinal substitution techniques, in the ongoing transformations in intensive care medicine, etc. This development, however, is a strategical decision made by the surgical communities concerned. How should The Thoracic and Cardiovascular Surgeon react? What should its strategy be concerning manuscripts on esophageal surgery? This journal regards itself as one still covering the whole spectrum of thoracic surgery and addressing an audience well beyond the German borders, at the same time being aware of our surgical heritage. We are therefore proud to be able to present to you two papers concerning this topic: a very interesting population-based study from Iceland and a case report which may raise striking associations with aortic surgery. If this generates your interest, we have won.

Let us contemplate the term “strategy” once more, trying to comprehend the lines of thought of consulting firms. These enterprises have a very mixed press with the medical community. The standard opinion there is that of a bunch of sleek, rather young, uniformly well-dressed people who earn a lot of money from telling doctors and hospital administrations relatively plain facts in order to help the hospital survive in an increasingly hostile and competitive environment. Such a survival strategy is commonly associated with cutting costs (i.e., jobs), at the same time trying to treat more patients in less time and with less resources (i.e., nurses and doctors). This opinion perpetuates the bad reputation and, though probably containing a fair amount of truth, must be considered a very superficial one. The intellectual preoccupation with the theories of strategy is bound to open the eyes of the interested doctor and will make him or her realize that there is much more behind it than simple reduction of means and increase of output. The basic dogma of economy “there is no such thing as a free lunch” is a universal truth. In order to be able to find a sustainable strategy for our surroundings, especially in these times of uncertainty, we have to take into account various influences, some of them rather unexpected [6].

Hospitals have to recognize that there is increased volatility in the market of health care with its new providers and concepts. The generally accepted ubiquity of information of the iPhone generation makes it of adamant importance to be/stay part of it, at the same time acknowledging its dangers. The necessary establishment of true interdisciplinary treatment poses the challenges of blurred boundaries within the hospital. The increasing costs and vanishing financial means of most health care systems evoke concerns about the implications for our fragile social and ecological environment. And finally, changing organizational structures, cultures, and values have destabilized the job market with an apparently increased mobility, but with a decline in security and motivation at the same time. This is probably the most crucial problem – how to motivate the best to pursue a career in medicine, especially the surgical disciplines, where the world is often still flat but the hierarchy overly steep, despite constant verbose assertions of the contrary.

By realizing the changes and by taking the appropriate steps we as cardiothoracic surgeons should be able to form the “new bases of competitive advantage” [6] in our field of clinical medicine. It is, however, our obligation to society to provide sustainability for a high level of care. History shows that it takes more than specialized knowledge but also literacy, tolerance, curiosity, and the willingness to accept alternative modes of thinking, be they dialectic, metaphorical, or even poetic, to create not only visions but long-lasting achievements. The pursuit of serious research and the publication of carefully prepared, honest papers may be a decisive step on the way to a successful strategy.

References

• 1 von Clausewitz C. Vom Kriege. Hinterlassenes Werk des Generals Carl Von Clausewitz in drei Teilen.. Berlin: Ferdinand Dümmler; 1832 – 1834
• 2 von Clausewitz C. Strategie.. Clausewitz Strategie aus dem Jahr 1804.. Hamburg: Hanseatische Verlagsanstalt; 1937
• 3 http://www.bcg.com/about_bcg/strategyinstitute/default.aspx accessed September 22, 2010
• 4 http://www.bcg.com accessed September 22, 2010
• 5 von Oetinger B. Hänsel und Gretel und die Kubakrise. 13 Wege, Strategie neu zu denken.. München: Hanser; 2006
• 6 Reeves M, Deimler M S. New bases of competitive advantage. The adaptive imperative (10/2009). http://www.bcg.com/documents/file33667.pdf accessed September 22, 2010