The Thoracic Surgeons:
Bogota, Colombia
K. Eckland, ACNP-BC, MSN, RN
The Thoracic Surgeons
K. Eckland
Copyright K. Eckland 2011
Published at Smashwords
All footnotes have been reformatted for use on electronic devices as text within parentheses for clarity in reading.
To the thoracic surgeons of Bogota.
To Jennifer Aisha Roberts, for all of her wonderful constructive input.
To Dr. Betty Heard, of Averett University for editing this work.
To the thoracic surgeons who trained me and helped further my love for thoracic surgery.
To my husband, Peter, for his endless patience.
Table of Contents
The Thoracic Surgeons of Bogota originated from a larger project on surgical tourism in Bogota, Colombia. During the process of writing that book, I conducted a series of interviews with multiple surgeons from different specialties across the city. Each specialty and each surgeon is unique, but the thoracic surgeons are a different breed from their counterparts in orthopedic, plastic and other surgical specialties.
In general, thoracic surgery is an unacknowledged and underappreciated specialty. There is no glamour, little glory, and no recognition of the specialized skills and knowledge they possess. Since its inception as a means to treat tuberculosis and similar diseases, thoracic surgery has existed to treat the illnesses of the impoverished and uneducated. Despite advances in technologies and treatments, these facts remain true, for the most part. This disproportionate thoracic disease burden is readily apparent in Bogota and in much of Colombia, due to widespread disparities in income and education. Bogota, specifically, is home to millions of people displaced by an on-going civil war and paramilitary activities, which contribute to the high incidence of thoracic diseases [Due to the lack of primary care and delay in seeking treatment among this large segment of homeless individuals]., along with a large percentage of tobacco users among the civilian population.
During interviews and interactions with these surgeons, it becomes apparent that in many cases the decision to pursue thoracic surgery as a career comes at considerable personal sacrifice. The heavy burden of thoracic disease in the less affluent public hospitals serving the indigent populations in the southern part of the city ensures a heavy workload but also guarantees much less financial compensation for services.
With a few notable exceptions, all of the surgeons profiled were born, raised and trained as thoracic surgeons within the maelstrom and vibrant mix of this sophisticated city and hillside slums.
For me, the decision to write about these surgeons was a deeply personal one. I have spent much of my career working alongside thoracic surgeons, and I believe their problems and frustrations with health care to be my own. As my research led me deeper into the depths of the subculture and subspecialty of thoracic surgery, I realized that the lives and stories of Bogota’s Thoracic Surgeons needed to be told, separate and distinct from the distractions of a larger book. This is not simply a directory of thoracic surgeons, but a detailed look at the thoracic surgeons as a group from a sociological perspective [Sociology as a discipline uses theoretical frameworks to discern patterns and explain behaviors within groups.].
I have included information collected as part of the larger effort because surgery and the role of the thoracic surgeon are the intrinsic part of who they are.
Author with Dr. Camilo Osorio
Thoracic Surgery as a specialty
Thoracic surgery is the specialized study and training on surgical procedures within the chest, above the diaphragm. This includes the lungs, the chest wall, and the structures of the mediastinum. There is no clear, universal delineation among surgical specialists, and there is some overlap among specialties, particularly among cardiac and thoracic surgeons. Many of these divisions are historical and based on the local tradition among providers, not training, such as operating on the thyroid. For example, thyroidectomies can be and are often performed by thoracic surgeons, head and neck specialists and general surgeons. Much of this work is determined by individual surgeons or hospital facilities, regardless of specialty training or background.
However, there is one significant difference among thoracic surgeons in Colombia, as compared to thoracic surgeons in other countries, which appears to be almost universal. This is the delegation of esophageal surgery to general surgeons due to the lack of specialized training in esophageal surgery in El Bosque [This is an area of thoracic training that differs significantly in Colombia from that in North America]. The sole exception, listed in this book, is a surgeon with extensive esophageal surgery training and an active esophageal surgery practice.
While the thoracic surgery specialty is relatively unknown in comparison to other surgical subspecialties such as neurosurgery, plastic surgery or orthopedic surgery, it remains a critically important subspecialty. Thoracic surgery procedures include lung resections for lung cancers, treatment of other pulmonary conditions such as empyema, pneumothorax, and pleural effusion, as well as all other non-cardiac procedures involving the chest, such as diseases and conditions of the diaphragm, esophagus and chest wall.
For all patients seeking thoracic surgery, it is important to verify that the operating surgeon is a specialty trained thoracic surgeon. All of the doctors listed here meet this criteria, as thoracic surgery specialists.
Surprisingly, despite the specialty knowledge required, and significant research detailing improved surgical outcomes when thoracic surgeons perform thoracic procedures, the majority of thoracic surgery in the United States is performed by general surgeons. This leads to an increased incidence of post-operative complications [Schipper, P. H., Diggs, B. S., Ungerleider, R. M, & K. F. Welke (2009). The influence of surgeon specialty on outcomes in general thoracic surgery: a national sample 1996 – 2005. Ann Thorac Surg, 2009; 88; 1566 – 1573.]. This phenomenon occurs most frequently in smaller hospitals in the United States, where patients’ knowledge about the availability of, or access to, specialty surgeons may be limited.
Why are the Thoracic Surgeons in Bogota important?
There are multiple reasons why a detailed look at the thoracic surgeons of Bogota is important. Primarily, it gives readers an inside glimpse into the lives of specialty surgeons and into the attitudes and perspectives of these surgeons as both individuals and as part of a small, exclusive group.
From a more practical, business standpoint, it is vital that Americans look outside our borders and forge relationships with our international colleagues. As part of this process we must examine both their surgical practice as well as attitudes towards treatments and new technologies. By doing so, we do more than broaden our knowledge base; we learn new techniques and innovations within our field, and we also are better equipped to deal with many of the issues facing American medicine, surgery and thoracic surgeons.
As the numbers of thoracic surgeons dwindle in the United States due to impending retirement, with little hope of relief due to a high vacancy rate within thoracic surgery training programs [Due to impending shortages caused by advanced age of existing US surgeons, and vacancies in existing training programs. Also, many cardiothoracic surgeons in the US elect not to practice thoracic surgery], as medical providers it is imperative that we seek solutions. These solutions will, by necessity come from outside the United States. For that reason, these international networks will help ensure that our patients continue to have access to high quality surgical care by specialty trained thoracic surgeons.
Currently, in the medical tourism industry, there is no ‘destination of choice’ for thoracic surgery, as exists for other specialties [For example, India and Thailand dominate the heart surgery market, and Brazil is the “known” destination for plastic surgery].
The thoracic surgeons of Bogota and in Colombia in general are important to the future of thoracic surgery. Bogota serves as a snapshot for much of the world outside of the United States. As our healthcare system continues to crumble and we attempt to find ways to stem hemorrhaging shortfalls, we must choose our successors with care. Some of the factors involved are external, such as the geographic proximity to the United States, the ease of travel, and the cost of care.
Other factors, such as the educational background, specialty training, surgical techniques and treatment philosophies are central to the surgeons themselves. By examining this small group, we are able to judge thoracic surgery in Bogota and in Colombia as a whole.
Surgical Procedures/ Technology
In modern surgery, many of the thoracic procedures can be performed by VATs (video-assisted thoracoscopy) resulting in smaller incisions, faster healing, and less pain for the patient versus traditional open incisions. For some thoracic procedures including removal or resection of very large chest tumors such as thymomas, or sarcomas, an open incision may be required.
Bogota surgeons, for the most part, have embraced and adapted to the use of newer technologies such as VATs. In my observations with both American and Colombian surgeons, Colombian surgeons utilize minimally invasive techniques such as VATs more frequently than their American counterparts. This may be in part due to the younger ages of the surgeons participating, but that is mere speculative theory on my part [The theory assumes that younger surgeons are more willing to embrace, accept and adapt to newer technologies]. Unfortunately, no statistics or reports exist to quantify or validate this observation.
In addition to the usual range of thoracic procedures performed in the United States, thoracic surgeons in Bogota frequently perform sympathectomies. Thoracoscopic sympathetomies are used to treat hyperhidrosis, Reynaud’s disease and excessive palmar sweating. This surgery is gaining popularity in larger thoracic surgery practices in the United States. The surgeons in Bogota also perform a wide range of mediastinal surgeries for mediastinitis and other complications from open heart surgery [Since surgeons in the United States typically perform both cardiac and thoracic surgery, cardiac surgeons usually perform their own mediastinal revisions in cases of infection after heart surgery]. Thoracic surgeons also perform specialized pediatric procedures such as thoracoscopic correction of sternal deformities such as pectus cavernosum.
History of Thoracic Surgery in Colombia
In Colombia, there is currently only one thoracic surgery program, located at El Bosque, with primary residency training sites at Hospital Santa Clara and the National Cancer Institute.
It was here, at Hospital Santa Clara, that thoracic surgery first emerged as a specialty in Colombia. Hospital Santa Clara, in downtown Bogota, was founded as a treatment center for tuberculosis in 1942.
In September of that year, Dr. Antonio Carlos Arboleta Acosta performed the first thoracic procedure, drainage of an empyema [A lung infection characterized by the development of pus in the pleural space, (or the area surrounding the lung.)]. In the fall of 1943, Dr. Jorge Diaz Humada, assisted by visiting American surgeon, Dr. George Humphreys, performed a pneumonectomy [A pneumonectomy is removal of one entire lung ] for a young tuberculosis patient for treatment of her disease. Thus, the first thoracic surgery service line was started soon after the hospital’s opening.
From here, many of the sources for historical information diverge into two camps, but the theme remains the same. While some sources site Dr. Jose Pablo Leyva Urdaneta as the first Colombian-born, thoracic surgery trained surgeon [Dr. Leyva, a native Bogotano, completed his thoracic surgery training at the University of Chicago prior to serving as a combat surgeon in World War II.], others make the same claim regarding Dr. Camilo Schraeder. Among Colombian surgeons, Dr. Schraeder is heralded as the first Colombian thoracic surgeon. He is known as the father of Colombian thoracic surgery and the founder of the thoracic surgery specialty training program. Many of the older and second generation thoracic surgeons recall Dr. Schraeder fondly, from their residency. However, during the development of the thoracic surgery program, there were internal conflicts that led to the division of the program into two programs for several years. This caused significant problems and divisions within the thoracic surgery community, which will be discussed later.
Medical Training and Education in Colombia
The main difference in medical training and education in Colombia in comparison to the United States is the lack of a previous undergraduate degree. While American medical schools require an undergraduate degree in biology, anatomy and physiology or music, as the case may be, in Colombia, students apply directly to medical school after completing high school. Medical school in Colombia is a six-year program, and after completion, physicians complete additional residency programs in their desired area of specialization.
In comparison to several other countries, Colombia’s surgeons and training programs for cardiac and thoracic surgery provide the greatest approximation to American training. Thoracic surgery in Colombia is an independent specialty and requires a general surgery residency as a pre-requisite to entry into fellowship training, which is not the case in many other countries [Wood, D. E. & Farjah, F. (2009). Global differences in the training, practice, and interrelationship of cardiac and thoracic surgeons. Ann Thorac Surg. 2009 Aug; 88 (2); 515 – 21.].
Group Characteristics
The twenty practicing thoracic surgeons make up a predominantly middle-aged male group, with Dr. Martinez as the sole female thoracic surgeon operating in Bogota. Out of the four current thoracic surgery specialty residents (fellows), there is one female resident. While the surgeons range in age from early thirties to mid-sixties, the average thoracic surgeon is in his late thirties or early forties. This makes the surgeons in Bogota considerably younger than their American counterparts. In contrast, the average age of American thoracic surgeons is 56 – 57 years old, and facing retirement [2010 report from the American College of Surgeons]. The majority of surgeons are Bogotanos, or natives to Bogota with a few surgeons from outlying and coastal areas [All of the surgeons are Colombian born.] As a group, they are fairly homogeneous with similar backgrounds, education and familial socio-economic status [With outliers are described further in the text]. However, there is wide variety in financial compensation among the group which has been a significant problem within the community.
Theoretic Basis for Sociological Analysis
Even the most basic sociological principles of Emile Durkheim on social solidarity highlight the importance of the inter-relationships among this small group. While the theories of organic solidarity are often applied to populations and societies as a whole, a selected application to the thoracic surgeons of Bogota as its own entity enforces the necessity of unity and social cohesion within the group to maintain the dignity and independence of its members [Durkheim, Emile, (1893). Professional ethics and civil morals. English translation]. Durkheim argued that social cohesion was an essential component which existed through the collective consciousness or shared attitudes or beliefs of a group. This unity was necessary to maintain social justice, ethics and divisions of labor within a society. This is certainly true of the thoracic surgeons of Bogota and becomes clear when we apply this framework to examine the issues facing these surgeons.
Group Dynamics and Cohesiveness
Thoracic surgery and thoracic surgeons have essentially existed for three generations in Bogota, and there are clear divisions maintained across these lines [Based on the author’s observations and multiple interviews].
Of this first generation of surgeons, who came after the initial pioneers, only Dr. Hernando Russi Campos and Dr. Casallas remain. The second generation of thoracic surgeons who followed (Beltran, Buitrago, Garcia-Herreros, Granada, Lopez, Martinez, Renteria and Tellez) endured the division of their specialty into two camps during the period when Dr. Camacho ran the Santa Clara residency program after the successful ousting of Dr. Camilo Schraeder. Dr. Schraeder then developed the competing program at the National Cancer Institute located a scant five blocks from Santa Clara.
Many of the surgeons of this generation inherited much of the animosity between Schraeder and Camacho, which is still evident in some of their interactions today. During interviews it is evident that old grudges between competing factions have been nursed and kept alive even though both of the principles, Dr. Camacho and Dr. Schraeder, are now deceased.
Others, like Dr. Martinez, who was one of Dr. Schraeder’s first residents, have been able to move past this complicated history to run the re-integrated Santa Clara residency program [Dr. Edgard Eduardo Gutierrez Puente was the last graduate of the National Cancer Institute residency program before it was re-integrated into a shared residency program with Clinica Santa Clara]. Dr. Buitrago and Dr. Beltran have remained at the cancer center and have carried on Dr. Schraeder’s legacy of excellence and on-going cancer research.
The third generation of thoracic surgeons, which includes recent graduates such as Dr. Jimenez, and Dr. Barrios, as well as more experienced surgeons such as Dr. Garzon and Dr. Franco, appear to approach thoracic surgery and their fellow surgeons with a different outlook. It is this last group of surgeons that seem to be attempting to bridge the gap among the group, through meetings, conferences, and shared thoracic interests. There is a concerted effort among this generation to strengthen the presence of thoracic surgery in Bogota and to establish themselves as modern practitioners, well-versed in the latest research and surgical technologies.
However, the cohesiveness of the group in general is poor despite efforts by members of the youngest generation (Garzon, Jimenez) to affiliate and advance the profession as a group through monthly meetings and annual symposiums. There is also a lack of interest and participation by multiple members in these activities which prevents the development of further group unity and allegiance.
An example of this lack of cohesion and goodwill towards colleagues was evident during the research and writing of this book. While many of the surgeons interviewed were enthusiastic and willing to introduce and refer the writer to surgeons outside of thoracic surgery, even at great lengths or significant inconvenience to themselves, this did not extend to their closest colleagues. Few were willing to assist in locating contact information for local colleagues, even when these surgeons shared a facility or office, and were even less likely to offer introductions, either by phone or in person. Several thoracic surgeons seemed offended or irritated by the request, which appeared to be independent of the level of participation or enthusiasm demonstrated in this project.
The importance of these group dynamics and cohesiveness is highlighted when looking at the current practices of the thoracic surgeons in Bogota as well as potential future practice. When examining the current practices of the thoracic surgeons in Bogota, two things are immediately apparent; there is significant practice overlap, and these surgeons are currently underutilized. This has serious ramifications for both their potential earning and the future of thoracic surgery in this city.
Practice Overlap
Multiple surgeons operate at multiple hospitals criss-crossing the city, barely acknowledging each other except when covering for vacations and days off, rather than forming dedicated thoracic surgery service lines. One surgeon may operate at five different facilities and be in direct competition with an additional five to ten colleagues. Usually these facilities are not geographically convenient to each other, and given the state of Bogota traffic, exceedingly wasteful of the physician’s time. It can take as much as an hour to cross the city at peak traffic flow, and these doctors may spend several hours visiting the different hospitals to see just one or two patients at each. Some of these scattered patient services are the result of a three-tiered medical system, but much of it is the result of fractured physician relationships. If the surgeons could form cohesive practice relationships with one or two colleagues and divide the hospitals in a more scheduled format [There is some scheduling, but it appears to be in a fairly haphazard fashion as each doctor still drives to multiple facilities to see his patients each day].; their time could be better spent in the operating room, and in patient consultations, which directly benefits their practice and their income.