Innovation has been fundamental to the wonderfully rapid progression and improvement of cardiothoracic surgery. ‘No pain, no gain’ [1], reported an innovative approach to oesophageal cancer in the University of Minnesota Hospital that exposed the surgeons to potential criticism. Had I been consulted about Andrade and Bhargava’s proposal to provide palliation for a frail 81-year-old man by reaming out an oesophageal cancer via a retrograde transgastric endoscopic approach, I would have cringed. However, it worked and the man returned home to continue to care for his ailing wife. Perhaps even more important than this success are the author’s sensitive comments about innovation in surgery.
Owen H. Wangensteen (1898–1981) was the University of Minnesota’s department chairman for 47 years. He was a foremost champion of surgical research who considered it his job to hire the best people, and then to find ways to make it possible for them to do their work. His residents included C. Walton Lillehi, F. John Lewis, Norman Shumway and Vincent Gott, each of whom made an impressive number of lasting innovations to our specialty.
I was born in Vienna in 1931 when physicians and surgeons from around the world flocked to the University of Vienna for postgraduate education. My father inspired me to become a physician (Fig. 1).
My research in thoracic surgery began as a University of Chicago freshman medical student. I studied fluctuations in oxygen saturation using one of the world’s first oximeters, while William E. Adams, a past president of the American Association for Thoracic Surgery operated. Professor Dr Adams’ primary research interest was lung function after pulmonary resections. He sent me to the laboratory to assess the feasibility of lung transplantation [2]. Sixty-seven years after I was given an oximeter, I have a perspective regarding the pull and tug between innovation and the protection of patients from research adventurism.
Richard Bienenfeld, MD, my father, during his residency at the University of Vienna in 1925, is in the centre of this photo.
Gone are the days of Theodor Billroth (1829–1894), the king of surgery at the University of Vienna, who is said to have predicted that no one will ever operate on the open chest. Ernst Ferdinand Sauerbruch (1875–1951) demonstrated a pressure chamber for operating on the open thorax in 1904 in Germany, 2 years after graduating from medical school. Alfred Blalock (1899–1964), prompted by Helen Taussig, accomplished the first successful treatment of Tetralogy of Fallot with a subclavian-pulmonary artery anastomosis in 1944 at the Johns Hopkins Hospital. I believe Billroth, Sauerbruch, Blalock and Wangensteen were kings in their respective realms, each able to try what he thought to be reasonable, without confronting a patient protection bureaucracy.
Now, there is a highly developed system to protect patients. It includes local Institutional Review Boards and government agencies like the United States, the Food and Drug Administration and the European Medicines Agency. Some healthcare professionals, pharmaceutical and device manufacturers argue that the patient protection bureaucracy impedes progress and adds expense to healthcare. There is no easy answer to these divergent viewpoints. I can argue that properly educated and experienced surgeons should be given freedom to try what they may, and I can vigorously support the viewpoint that patient safety and protection take priority.
When I read ‘No pain, no gain’, I found it refreshing that the University of Minnesota still provides the environment in which innovation is possible and appreciated. Research and innovation are the engines of improving patient care. We must insist on a balance that preserves the possibility of trying new approaches, and yet be ever vigilant to protect our patients.
Conflict of interest: none declared.
