Dr. George Tolis on Physician Pay, Private Practice, and a Valve Gone Wrong

Episode Summary

Cardiothoracic surgeon Dr. George Tolis, chief of cardiothoracic surgery in Boston, returns to The Doctors Lounge with hosts Dr. Anish Koka and Dr. Anthony DiGiorgio for a wide-ranging conversation that opens with the newly proposed 2027 Medicare physician fee schedule and the budget-neutrality rule dating back to 1989 that forces cuts to one specialty to fund raises to another. The conversation moves into why true independent private practice has effectively disappeared, how hospital systems control physician hiring, firing, and pay regardless of what Medicare reimburses, and how locum tenens pay and device pricing expose the arbitrariness of professional fees. The back half of the episode turns to a widely discussed case of a cardiac valve implanted upside down in a young patient, with Tolis walking through how tunnel vision and ECMO can mask a never event for days, why he holds the surgeon fully accountable while condemning the social media pile-on that followed, and how palliative care should never be initiated without physician involvement. The episode closes on innovation in cardiac surgery — minimally invasive and robotic mitral repair, the Ross procedure, bilateral mammary artery use, valve selection, and how thirty-day outcome metrics quietly discourage surgeons from doing what's best for patients long-term — along with a candid discussion of industry money and conflicts of interest in medicine.

Chapter Markers

00:00 Welcome back, Dr. George Tolis

01:09 The proposed 2027 physician fee schedule

05:20 Budget neutrality since 1989 and the flat physician bucket

10:09 Tolis: physicians are compensated less, not necessarily paid less

16:41 Barriers to going private and the PSA model

21:03 The painful transition to an independent physician ecosystem

25:25 Locum tenens pay, valve pricing, and "it's all by design"

33:51 The case: a valve placed upside down

40:01 Tunnel vision, distraction, and 110% concentration in the OR

50:45 Palliative care involvement and the organ-harvesting narrative

55:50 Reader comments: minimally invasive mitral surgery pushback

1:03:02 Competition, capitalism, and information asymmetry in medicine

1:13:02 Bio AVR vs. mechanical valve in a 57-year-old

1:15:28 Bilateral mammary arteries and the 30-day outcomes problem

1:17:46 Prospective payment, DRGs, and device cost incentives

1:25:08 Industry relationships and physician disclosures

1:29:05 GLP-1s, honoraria, and what counts as conflict of interest

Co-Host Handles

@anish_koka and @drdigiorgio

Show Handle

@drsloungepod

Subscribe Links

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Dr. George Tolis's Previous Appearance on The Doctor's Lounge

Dr. Tolis first joined The Doctor's Lounge about two months ago. Watch that episode here:

https://x.com/DRsLoungePod/status/2055619280855515141?s=20

Dr. George Tolis on X

@georgetolisjr

🔗 Connect with the Hosts:

• Dutch Rojas on X

• Dr. Anthony DiGiorgio on X

• Dr. Anish Koka on X

• Dr. Dan Choi on X

• Dr. Sanat Dixit on X

Transcript

Anish Koka MD: Hey, we are live. Good evening everyone. We have Dr. George Tollis, a returning guest today, on the Doctor's Lounge. Dr. Tollis was one of our most popular guests. shows what he can pull. Dr. Tollis, you are a social media star. So we had a very interesting episode on the last what about a few months ago and really fantastic. we'll link to that.

George Tolis MD: Well, the keys still working the office door, so I guess do

Anish Koka MD: Yes,

George Tolis MD: it again.

Anish Koka MD: so we so yeah, so we'll link to that on the show notes in terms of what he had before. But for those who don't know, Dr. Tullis is a cardiothoracic surgeon. He posts thoughtfully, sometimes very bluntly, about surgical practice, training, things like valve durability, medical education, leadership. and he's a chief of cardiothoracic surgery in Boston. and we're super happy to have him back. So Doc Tolus, welcome back.

George Tolis MD: Thank you very much for the invitation.

Anish Koka MD: so we thought we'd start with something that's been tearing up the news when it comes to physicians. and it's something that's near and dear to physicians, something that most physicians probably don't have a fantastic understanding of, and certainly most patients kind of don't have an understanding of it, but it's the proposed rule to the physician fee schedule that came out last week. this is from Medicare. it involves some rules and procedures regarding how physicians are paid. there's it's a very long document, it's like fifteen hundred pages, but there was some stuff that was pretty what's what's a good word? Pretty upsetting to a fair number of physicians. But i d I thought we'd start with just understanding a little bit about the physician fee schedule. Doctor DeGiorgio, can you tell us a little bit about where the physician fee schedule kinda came from?

Anthony Digiorgio MD: Great question. And I think it's worth noting that CMS released proposed fee schedules for both the inpatient side, the outpatient side, and the physician fee schedule. So there's a number of fee schedules that were released and there are these proposed rules that would go into effect for 2027. And the physician fee schedule governs how much doctors get paid for their CPT codes. so the prospective payment system, all the everything a doctor does gets a CPT code and the physician fee schedule decides how much you get per CPT code and get per RVU. So there's the conversion factor which calculates the dollars per RVU. Now the way that CM the way that the Medicare statute is written is it has to be budget neutral. if there's more essentially if there's more RVUs floating around in the system, doctors get less dollars per RVU. And which makes it really unfair because you essentially, if you want to pay your primary care providers more, you have to take away from the specialists or vice versa. you essentially have to rob Peter to pay Paul. what the 2027 physician fee schedule did is gave a cut generally to the RVU conversion factor. It depends if you're in certain payment models or not how much that cut is. But what they also proposed what is called an efficiency adjustment where they will take away RVUs two point five percent to be exact from procedure codes with the hope that that would bump up the primary care codes. so your basic office E and codes would get more. they also cut some specialists, the orthopedic surgeons really got hammered with this, received about a 10% cut on top of that. the number going around on Twitter is something like five hundred dollars for a knee replacement now, which also includes, you know, 90 days of post operative care. So it's easy to for physicians, especially specialists who do a lot of procedures, to get upset about this. But again, I tend to cut CMS a little bit of slack here because I understand the desire to pay primary care more. I certainly agree with that. I don't like that it has to come at the expense of specialists, but statutorily that's what they're required to do. So if you want to change that, it literally takes an act of Congress, which would be nice if they could get that changed. On the flip side, the inpatient and outpatient physician fee schedule I think have a lot that we can like number one is there's some 340B reform, which anyone who knows me knows that gets me a bit excited. so I'm happy that they are taking some steps at curbing the 340B program within Medicare. there's some language about site neutrality, especially with radiology, where they're gonna stop paying inpatient or hospital based radiology images a lot more than independent clinic radiology. I think there's some things to like. again, I feel bad that CMS has to go about this to try to pre primary care more. but Anish, Doctor Tolis, what are your guys' thoughts?

Anish Koka MD: Yeah, one of the things that folks don't realize, which is exactly what Anthony was just saying, was this budget neutrality requirement that went in in nineteen eighty nine. as part of some the budget some budget reconciliation act of nineteen eighty nine specifically looked and specifically targeted the bucket that is used by Medicare to pay physicians and made that budget neutral. So yes, it is the case that Medicare has been paying more and more out year by year by year. The only place, the only folks in this Ecosystem, you know, there's physicians, there's health systems, there's pharmaceutical companies, home care, a variety of different things. the only group that has had their amount that they've been paying out flat since that 1989 number is physicians. So yes, so you know the numbers are pretty stark. Medicare has gone up from six hundred and about six hundred fifteen percent from nineteen eighty nine, you know, gone to like nine hundred and forty six billion dollars from one hundred and thirty two billion dollars. But yet physician, what's going to the physician bucket is basically flat. compared to inflation, physicians have actually had a pay cut for about thirty percent. so it's a pretty stark reality that I don't think I don't hear talked about much is that o only physicians are the ones that are kind of forced to live in this balanced neutral world, balanced budget world, that means exactly what Anthony's saying, that if you pay primary care physicians more as part of the physician fee schedule, the only way to make that work is to pay somebody else less. And the question is, who do you pay less? this is one of the many things that underlies why over time, health systems have become so incredibly powerful because the health systems have been, getting increasing amounts of dollars over time. but, you know, physician if you keep physician reimbursement revenue to the physician fee schedule flat, then you know, in order for physicians to get more of that pie, the only thing they can really do is go and join the health system, and the health system then will kind of give you a portion of that larger pie that they have successfully lobbied Congress to get, physicians have not been successful in lobbying Congress to keep to keep you know increasing like like everyone else. and of course the insidious thing about that is that it's physicians then negotiating with hospitals to get a portion of that pie. And guess what health systems do? when physicians come to the table and say, Hey look, we believe our work is worth this much because Again, at all revenue in the health system comes because of some physician, and the vast majority of it comes from physicians doing services, physicians performing a procedure. so so then, you know, health systems will say, look, we're getting less and less from Medicare. What can we do? We can only pay you X, Y, and Z. So the whole system is set up to take somebody like Doctor Tolis, and Anthony both incredibly talented individuals and kind of make them subservient to the health system, Dr. Tolis is one of the few people in the world that can crack open a sternum, you know, arrest a beating heart, cut into the heart, replace a diseased valve, and and then have that person be walking, talking five days later. and the vast majority of the dollars that go to do that incredibly miraculous thing is going to the health system and not to doctor Dr. Tolis. yeah if we want to change that requires kind of a change of law. Dr. Tolis, how were you kind of aware of all of these things as you were becoming you know bec in training, becoming attending or when did it start to kind of understand some of these things?

George Tolis MD: I would say that I was completely oblivious to them when I was a resident. And I think that I understand most of it now, although I certainly don't understand, the I don't get the entire picture. I'm not sure anyone really gets the entire picture. But whenever something is so complicated, I think it's good to just establish facts versus fiction. So the bottom line is that physicians are being compensated less, they're not necessarily making less money. because at the end of the day, if you're gonna pay someone, you know, 50 grand a year to do 200 pumps, you're not gonna find anyone. If you pay someone seven figures, you're gonna find a lot of people that are very interested in doing that. So, what hospital systems do is they They try to figure out how much money they need to pay someone to do the work. Now, then they need to decide what kind of person do they want. Is this a hospital system that no matter what happens outside, they will always have patients because of reputation, because they're the only show in town, they're the only whatever. If they have significant control over a patient population. Then unfortunately, what these systems will try to do is they will treat the physicians as simply the in our field the plumbers, and they will discard the system from the physicians developing relationships with the referrals because they want full control of their referrals and they just want you to do the cabbage, they just want you to do the AVR. And they will decide how much to pay you, and you can decide whether you want the job or not. The change it now another system that needs to compete with a better-known system, they're the ones that will be willing to pay extremely competent, extremely senior people more because they realize that in order to compete with a big show in town. They need to offer something better and something more efficient. So it is sort of these relationships that define how much money a surgeon will make. Again, I'm using very broad terms here. But you'll notice that how much money the surgeon makes has nothing to do with whether Medicare, cut 5% or 2% or 1%. But what it does is it gives the system full control. Over the hiring, the firing, and the salary of the people that do the work. Now, if what can you do as a physician to fight this, to play with this, to survive in this? You have to identify a system for which your talents is something that they're looking for. So for example, if someone who's one year out or two years out goes to a smaller system that needs to compete with more powerful players and says, Yeah, listen, I'm a good guy and I finished two years ago, and the folks are gonna say I'm not interested. If that person goes to a well-established machine, that no matter what happens, no matter what the mortality is for a few years, they will always have their referrals. That is a very attractive candidate for that institution. So But at the end of the day, all these changes and all that stuff, it's all about control. And when the physician compensation for a cabbage or for the orthopedic procedure for a knee, I think you said is five hundred bucks, you know, try to find a plumber to come to your house for something that, is worth to them less than five hundred bucks. You're not gonna find anyone. You get a plumber, you get an electrician in Boston to work in your house. it's gonna be three figures. You you're not gonna find someone to come in just you know screw something screw a bulb or even if you call a service to you know to do something very basic, they're gonna charge you an arm and a leg. More more so than what the orthopedic surgeon charges for a knee in three months follow up. So these numbers have nothing to do with reality. All they do is they enable a hospital system to control the hiring, the firing, and the pay. That's about it. Now, the whole thing about you know reverse engineering the RVUs and blah blah blah and all that stuff, all that is, is it provides someone with a platform to explain a salary that has been predetermined. because you can play with y you you can check what you know state A pays per RVU versus State B, and it's gonna be night and day. You can see what hospital A pays versus hospital B. And it is, you know, the the differences are huge. So the ship has sailed in terms of physicians being surgeons being independent and that can survive based on the physician fee. what that means is that The we lost out her D. Georgia, I think, right?

Anish Koka MD: Yeah, he'll come back.

George Tolis MD: I think all it means is that control has been seated the hospital system.

Anish Koka MD: Yeah. you explained that nicely. there's a number of levers that seem to be involved here in terms of how, control is exerted. one of the things, said Dr. Charles Lutz, who's a cardiothoracic surgeon as well. he's actually one of the few folks that have actually gone private again, or in private practice. do you know Dr. Charles Lutz, Dr. Tolus? Have you heard of him? I can't remember where exactly he is, but he talked about how he's a member of a private group with a hospital PSA from twenty twelve to twenty seventeen. he says, we never gave up a private group even when we became employees, which then provided a leverage for return to that PSA model. can can you talk a little bit about what the barriers are? 'Cause a lot of people hear that are like, That sounds like Greek to me. What are the barriers for a cardiothoracic surgeon who is in an employed model to go private?

George Tolis MD: Well, going private, all it means is that you collect your own professional fees. but let me put it that way. In nineteen ninety, the professional fee for a bypass operation was I think six thousand dollars or something. if you were some assistant that came in just to harvest Bane at St. Vincent's Hospital in New York in the year 1990, you're getting paid fifteen hundred dollars a pop. So there are people, again, this is 1990 money, that did not take call. All they did is they went to the first assistant and they took vein. And they were getting paid fifteen hundred bucks. They did that for 400 cases a year, they would make six hundred thousand dollars in nineteen ninety. That's a lot of money. Today, that was a lot huge amount of money in 1990. so if a physician back then could do 200 or 250 cases and was collecting, you know, five to six thousand dollars a case, that's a lot of money back then. That's a buttload of money. Today, if you're a heart surgeon and you're a busy heart surgeon, which means that you're doing 200 to 250 cases a year, and the majority of your cases are Medicare, and let's just assume that they're all insured, and that you collect between $1,500 and $2,000 per case. What that means is that the maximum amount you can bill is four to five hundred thousand dollars. Now from that you're gonna have to pay rent for your office. You're gonna have to pay your secretary, you're gonna have to pay malpractice insurance. You might as well be a PA. And, just work 40 hours a week and that's it. So private practice, in the true sense of private private practice, does not exist in this country. All these private practice groups are subsidized by the hospital. The first job that I had at Lennox Hill in New York, with Dr. Sue Romanian. That was a private practice, but he was subsidized by the hospital. And the reason why public, I mean private practice, quote unquote, still exists, well, that tells me is that specific surgeon must either be the only show in town or other practices must have tried and failed because they didn't hire the right people and they could never maintain a volume. And I suspect that that kind of practice is there might be one or two other hospitals in the area that every couple of years they bring some surgeon from outside who comes in, fails, leaves, then another one comes in. That's usually the pattern. Or that's the only show in town. And, you know, it is too costly for the hospital to try to fight that group and create another group. Something very similar existed here in Massachusetts with Bay State. in Springfield Mass, which in the nineties was a huge group and it was, you know, a very productive group. I don't know what their finances are now, but Spring but Bay State is not a huge player in Massachusetts anymore. And they have basically followed the sort of demise of private practice, which I think is a national trend.

Anish Koka MD: Go ahead, Anthony.

Anthony Digiorgio MD: Well, I think that it's worth talking about these other changes where potentially seeing less money come to the hospital systems as well. And this is a point that Anisha and I talk about quite frequently that if you are going to reverse this trend and get back to where you have a thriving independent physician ecosystem, there's gonna be some pain in that transition, right? If you're telling us, Dr. Tolis, that The way that the system can afford to give that cardiothoracic surgeon what they can get on the open market is by harnessing revenue that comes from facility fees, other outside source of revenue like 340B, dish payments, these other subsidy streams that hospital systems get. If that's the only way they can pay that surgeon what that surgeon thinks they're worth, and we also cut back those revenue streams, this is gonna be a painful process by which the we are gonna get to a a system that rewards independent physicians. I'm curious in your mind, how do you think that we make that transition happen and make it as painless as possible? And or can we?

George Tolis MD: Well, I think that it's gonna happen with a combination of it depends on how reproducible the final product is. If it truly takes if it matters how good you are in terms of how good the outcomes are, and that is a measurable number, then physicians will still command higher salaries that can do the job better and more efficiently. So if you you know if you have a hospital that needs to do two Cases a day, and one surgeon can get the two cabbages through, but it takes them, you know, six hours per cabbage, and the hospital has to be overtime and you know, staff that has to stay through eight or nine o'clock at night, versus have a surgeon who can do the same operation the same way and finish it in two hours per operation. then the hospital will be motivated to provide efficient turnover so that the team can be done by three or four o'clock in the afternoon. So the if the talent and the and the abilities of a surgeon make a difference in the bottom line, then that surgeon will be compensated. If they don't, then it's gonna be a lost art. It'll be someone that, just is there to do the job, to clock in from time X to time B, and that's the end of story. I would hope that in cardiac surgery is the former.

Anish Koka MD: it is frustrating because it seems like without some more fundamental fix, simply going down the paths we're going down right now are going to result in pain for physicians one way or or the other. Because, you know, it is you know, we we bang here health systems and how they're reimbursed all the time, but the reality is is that the large majority of physicians now, the reason they went to the health system model was to capture some of that revenue that was not flowing towards physicians directly. It's flowing towards physicians, as Anthony's saying, in the form of higher compensation for X, Y, and Z or facility fees, the technical component of these procedures. if you really significantly are able to compress those Then it does mean letting the air out of the system but letting the air out of the system will also involve, physicians who are certainly currently employed i in the employed model from getting hurt. And of course, it's also gonna hurt those who are being subsidized. So if a physician, if a private cardiothoracic surgery group is getting subsidized in the sense of money for taking call for cardiothoracic surgery. surgery cases, right? you know, there's gonna be less money to go less money to go around. so yeah, it it's a really it's a really t challenging situation. But I think one of the things is it it's really important that physicians kind of have an understanding of what exactly is going on. And if you don't quite understand some of these details, like you need a statutory fix. If you want to change the balance in terms of power, yeah, that 1989

George Tolis MD: is do you want to understand these issues in depth or is it enough to observe some things in the environment that make you understand that you know that the whole thing is a setup. and I belong to the latter category. I think that life is too complicated and I don't want to spend a year to understand exactly what is going on, but I can tell you different things that I observe. there's many locum tenants companies which basically find cardiac surgeons to provide coverage for a weekend. And I've seen how much they pay these surgeons basically to just provide coverage, and it's tons of money. Tons of money. I've never done it personally because I've been busy with my day job. But there's a lot of people that are making a very good living flying for a week to Kentucky and another week to West Virginia and another week to Florida and actually sending their kids to college that way. I think that is terrible medicine when it comes to cardiac surgery. I think it's insane to operate on someone and leave and never see them again and have someone else take care of the wound infection or whatever it is. But The hospitals and the locums companies are not doing this out of charity. They clearly have the cash to pay these surgeons that kind of money. So if the hospital has the money to pay the surgeon that kind of money and the locums company, where did they get the money? They got it from insurance. So the money is there. So that's number one. Number two, there's a valve. There's a bioprosthetic valve that costs, I think, $4,000. And there's another one that costs $7,500. And I've never heard the company that makes this valve saying, Medicare didn't pay us for the more expensive valve. Or I've never heard the ablation company say, Medicare refused to pay for the ablation clamp. or for the mitroclip, which is a piece of cloth basically that with a metal frame that covers the left atrial appendage and they collect twelve hundred bucks out of that. So I've never heard these companies say, we're gonna stop sending you the clip because you know insurance is not paying us. No. They never sweat that stuff out. That's the money is there for them to collect. So why is it that everyone else is getting paid and physicians' professional fees are coming down? It's all by design. And clearly the people that represent us think that it's okay for that to happen. So do you want to fight it? Do you want to pretend you don't understand it? it's entirely up to you? I think I understand it. I don't care to understand the full details about it because I'm very happy with what I get paid. I have a nice life. I can send my kids to college. I'm still married to the same woman, thankfully, so there's no extra money there. and you know, I have everything that I need and I don't need that much. So it comes down to what makes you happy at the end of the day.

Anish Koka MD: I think in the any landscape moving forward, having a very sought after skills, you're gonna come out okay. if you're one of the twelve people that can take somebody to the OR at two AM after a deck falls on you and you can't move your legs, you're gonna be able to command something somewhere in the system, what you can do. so I think, it's important to remember that a lot of physicians don't necessarily have this are on a small select band of folks and don't have kind of leverage that that you folks will have. So it's almost like, it it's interesting, Dr. Giorgio, I mean Anthony and and Dr. Tills understand this to a very deep level, but but they're probably the least the ones that could shut it off the most. Because it's all no it can be noise to them because, almost regardless of a system that you set up right now, their skill set is pretty unique. All right. So enough enough of depressing stuff. And we're gonna move on to something that's perhaps even more depressing. There's

Anthony Digiorgio MD: Before I do want to note that there is congressional action to change this budget neutrality and to fix the physician fee schedule. So there are advocates for us in the House and in the Senate that are working on these things. So it's not all doom and gloom. It's really hard to get these things passed because as you know, if you are going to pass something that adds to the federal deficit, you either have to have a filibuster proof majority or you have to find pay fors to offset those costs. And so when they send these things to the Congressional Budget Offit, they're very expensive. but there are there is good advocates for physicians in Congress that are trying to get this through. So it's not all doom and gloom.

Anish Koka MD: Great point. And I should also say that this is a proposed rule for twenty twenty seven. one of the rules in there involves if you're doing an ENM clinical evaluation and doing a procedure. So if you saw a patient for chest pain as a cardiologist and you order and perform the ultrasound the same day in your group or you do it yourself or whatnot, they're proposing cutting the less expensive procedure by fifty percent. I'm giving one example and I I think that's a very bad place to go go after for a variety of different reasons. it's all a little bit of a game, of course. this was proposed in twenty nineteen, a similar thing, because CMS thinks this is duplicative and not actually worth two separate full payments. You know, obviously you know, I disagree there are places where you can be duplicative. in twenty nineteen they propose the same rule. There's open comments. know, we'll provide a link for comments that are open till I think September 18th or something like that this year. So urge all physicians to, you know, read about it, learn about it. I wrote an article on a post on this on X and on Substack, just kind of going through and explaining some of this stuff as well. so we'll post a link to that as well to kind of you know and click on the link. Link, and your make your opinion heard. And of course, as Dr. Dujur says, the larger structural fix beyond this little nitpicking that that happens, does involve legislation that would change that budget neutrality. Something that Congress is not gonna want to give up. It's like, holy crap, how the heck did that go through? I mean what a fail that was on the on the part of physicians and our advocates that we alone in in 1989 had that happen. And the vast majority of physicians have no idea that even happened, right? it's not in our lexicon. The the other thing that we want to talk about, I was hoping you know, this happened about a month ago. When did this happen? this kind of made the rounds June. Yeah, right about a month ago. There was a surgeon in the organ system, I believe. Was it the or organ? I think organ system, a cardio cardiothoracic surgeon that operated on a young thirteen-year-old girl, it was some valve disorder that the patient had. The the patient gets operated on and then the patient does really badly afterwards, like is kind of dying from the moment the surgery happens. so Dr. Tolus, do you remember this case?

George Tolis MD: Is that the one where the valve is placed upside down?

Anish Koka MD: Yes, correct, correct. can you if you do recall, because know you know, this is near and dear to what does you do? Can you walk us through some of the things that can happen here and why this may have happened?

George Tolis MD: Sure. I don't know the details about this case, but the I would suspect that most likely this was a mechanical valve and not a bioprosthetic valve. Because the mechanical valve looks fairly similar from both sides. Not exactly the same, but it looks fairly similar, the biletlet valve or the same Jude valve, like we you know, the most common valve that we use in the as a mechanical prosthesis. When you use a biopresthetic valve, a tricuspid biopresthetic valve, the the way that it looks from the that's the valve that looks like a Mercedes sign. when you s when you put it on the mitral position you see the back end of the valve. And when you put it in the aortic position you see the front side of the valve with the three posts that are sticking out. So I would think that if you put the a bioprosthetic valve upside down in either mitral or the aortic position, it would look funny right away. I can picture how a mechanical valve would not look funny right away, especially if you can't see it well and then it or if you're just seeing part of it. And that happens sometimes with a mitral valve. You don't have a full view of the whole valve at all times. so aside from that, that is no excuse. we talk about never events in surgery and things that should never happen. This is a never event. This is something that should never happen. This is one hundred percent the responsibility of the surgeon. why do I say that? The public thinks that if you leave a sponge behind that, the surgeon's so negligent and so this and that. Well, we all know that we rely very heavily and the OR staff to tell us that the counts are correct. especially in cardiac surgery, if you've packed something that was bleeding and then you unpack it to get out and close. If you leave a small four by four behind, you're not gonna see it. You need someone to tell you that that four by four is not there, or to wand it with the RF gadget or whatever you know sort of system you have to to check these things. But the valve is an absolutely 100% the surgeon's responsibility. There's no one else that can see the valve as well as the surgeon. So this is something that shouldn't happen. Now, why did it happen? I suspect that they took the valve out of the holder. because for whatever reason, I don't know if the surgeon takes it off the holder and has someone hold it, and that person inverted it when they when they presented it to the surgeons to put the sutures, but I suspect they must have taken it out of the holder. They inverted the position and the surgeon didn't realize that they inverted the position. Again, that is no excuse. That's something that should never happen. the surgeon is 100% responsible for this. I mean, I feel extremely sad for him and for the patient, of course, but the surgeon this is 100% the surgeon's responsibility. Now, this is also the the anesthesiologist or the cardiologist's responsibility who did the transesophageal echocardiogram in the operating room, because they should see if the valve is placed the right way or the wrong way. And they should see if the valve has a lot of leakage through it, which you would expect if this valve is placed upside down in the aortic or the mitral position. So there's a lot of failures in the system, but ultimately this is the responsibility of the surgeon. The one thing that really surprised me from this case was the venom that I saw on Twitter against the surgeon. Speaking of, trying to Hurt someone when they're down. you'll never see cops do that to each other. You never see firefighters do that to each other. Doctors, unfortunately, are very trigger happy when it comes to taking the colleague down. And I thought that was absolutely disgusting. No matter what you think about the guy and whether you'd let him operate on you or not. like I said, I think this is a terrible mistake and it's malpractice. There's no other way to put it. But The response that I saw on Twitter from colleagues was disgusting and disheartening.

Anish Koka MD: yeah, it was a surgeon who was extremely well trained. certainly not a case of, some poorly trained person that flew in to do something and the pedigree and the years of training were sobering in the sense that makes you realize how unfortunately all complications are like this. it's just things that you just never thought about that end up happening regardless of how often it happens. and I agree with you about that's an excellent point about the fact that cops make mistakes and fatal mistakes. and you don't necessarily see that same type of level of venom. But how does one go about making sure that this would never happen? is that something that's possible or is that just not possible?

George Tolis MD: Unlike most human errors, that are team errors and system errors, I think this is one hundred percent the surgeon. the surgeon is I mean there's only that much you can do with marking the incision and you know, marking the laterality and doing all that stuff. you know, you cannot mark the coronary arteries before you start the bypass. You just need to know what arteries you're gonna bypass. in similar fashion, you cannot mark the left atrium, and know that you're gonna do the mitral and not the aortic valve. And hey, you know, it's your responsibility to make sure that the valve is going in the right way. It's something so basic that you know, sometimes the most obvious things are the things that you miss. And I think that's what happened here. I'm i I don't think it has much to do with your training as to whether you know, you put the valve upside down or the right way up. This is just a lapse, this is not paying attention, this is I'm not making excuses for the guy, but this is just a one hundred percent a lapse in judgment. Someone who's not when you do an open heart surgery, you need to be 110% concentrated on what you're doing. Like I never play music in the OR. I never do any of that stuff. You just have to be one even when you're cutting the skin, you need to make a midline sternotomy. When you're cutting the bone, you need to make 100% sure you're not injuring anything underneath. 110% of your concentration is on the patient.

Anthony Digiorgio MD: I think that's that's a great point. and it goes to a bigger systems issue. This is something I brought up I think a few days ago, is that doctors will when things aren't a hundred percent correct, it takes our attention away from these things, like you're saying, you know, if you're having to futz with a computer that won't work in the OR or you're having equipment's not functioning properly or they can't find the right stuff for you. The nurse is bugging you that HP is out of dated, right? These things all distract you from having that focus. And I feel like when surgeons, especially employed surgeons, bring this up to their hospitals, it's not treated with the level of urgency that I think many surgeons feel it should be. On the other hand, if you're if that HP is late, if your discharge summary is 12 hours late, if you're not caught up on your modules, they will bring the full force of the administrative. staff down on that physician. and so there just seems to be this asymmetry in priorities in a lot of these large health systems. Sure, they'll probably make another thirty checklists to try to prevent this from happening again, but there's some things that just no matter how many checklists you make, it's not gonna work. But when a physician or a surgeon comes and says, Hey, these things are not right in the OR and it's taking away from my ability to safely perform surgery, a lot of time unfortunately that's ignored. but then Again, if they're not filling out their clicks and their check boxes, heaven forbid the the wrath that's gonna fall upon them.

George Tolis MD: Well, I I think what you say is very important that Unless the most things you can explain to everyone else. There are some things that you cannot explain unless you're a surgeon or a proceduralist. And it is very difficult for some people to understand that when they're arguing with you, when you're operating on someone, and maybe you're wrong, maybe you're not your the tone of your voice is not right, maybe you sound dismissive, but when you're concentrating on someone and someone is arguing with you about whether the flow was four or four percent. point five or whether the anti grade pressure was adequate or not adequate or the cardiac pledia was warm or not cold or whatever it is. What people don't understand is that you're getting distracted. when people are arguing with you, you're getting distracted. And what I've tried to do is clearly not to escalate, not because I learned that in a course or I read a module about it, but because if you escalate it, And it's human nature to escalate, I believe, because you know that the cardioplegia is warm and someone is telling you no, it's not warm, it's cold. And you put your finger on the aorta and the aorta is not cold. So you know exactly what's going on. If you do this back and forth, all you're gonna do is you're gonna get distracted, you're gonna miss something else in the field. So the best thing to do is, in my opinion, again, is to at times like these to just become this. completely cold hearted person, ignore everything and concentrate on what you're doing. And some people will perceive that as dismissive, as ignoring you, and they'll put that in the, pulse three sixty eval form and all that stuff. And then you have to talk to someone about it. But I still think it's worth taking that hit, in order to serve your patient better. You can deal with the coaches and all that nonsense later. But you have to concentrate on what you're doing. And I think that what happened here is this surgeon for some reason did not concentrate. Was he provoked? Was it because he was fighting with someone? Was it because he was fighting with his wife the night before? Who knows? But he got distracted. This didn't happen because he's not a good surgeon. This didn't happen because he trained a place A versus place B. This surgeon was distracted at the time when he was handed the valve.

Anish Koka MD: Yeah, so you're saying that wives should not argue with physicians. Most controversial thing. Doctor Tolus will not survive this this podcast.

Anthony Digiorgio MD: Honey, we can't have a fight. I have surgery tomorrow. Just admit I was right.

George Tolis MD: We had a cabbage tomorrow actually, so but but I had a very, very nice evening with my wife. She went to bed, so

Anish Koka MD: Just getting into the details a little bit about of the case. There a couple things here, One is of course the the surgeon was distracted and this horrendous thing happened. you talked about this, but I think one of the other things for physicians is this whole idea of anchoring to certain diagnoses, right? So it's really hard not to do, I think. when a patient isn't doing well, you automatically go through some differential in your head as you're supposed to and you don't kind of entertain every possibility. in this particular case, if you have a patient who say has some mitral valve disease, no doubt has some level of pulmonary hypertension. one of the big things, Dr. Tolis, when you're doing these type of cases, is seeing how the right ventricle will do, correct? you know, one of these cases that all of us have been a part of where the R V just kind of balloons and blows out after Afterwards, right? And we think it's because the R V didn't tolerate it, the R V was compromised to begin with, you're going in, you know, scheming time, etc. that type of case where the R V is just not working afterwards, correct? is gonna look very similar to this case, where the valve is not placed the right way. as somebody that does tease, I mean I don't know if I'd be able to recognize a inverted mitral vowel.

George Tolis MD: Again not being there. Not being there. I suspect I suspect that these are all good people. I think they're all good doctors and the Echo people and the cardiologists and all that. So this has to be a case of tunnel vision. and the second thing that's also a factor here is that and I you know, I'm I'm a little bit older than the the current generation doing this, but I grew up before the era of ECMO. Before ECMO, you had to get out of the room. the way you were with a balloon pump maybe. so you would try to come off, you'd look at the echo, you see what's happening, you try to figure it out. I suspect here what happened is this patient, they just, you know, failed to come off and then went straight to ECMO. Now ECMO can mask tons of things. Cause if you have someone on ECMO who has a mitral valve that is reversed, They're gonna have great hemodynamics. They're gonna have a very well drained left ventricle, an empty left ventricle, because it's draining into the left atrium. And I suspect that the left atrium must have filled up a little bit, so they must have put a vent in the left atrium. I think. I don't know. So if you're an ECMO with a reversed valve in the left atrial vent, or a PA vent for that matter, You're gonna be okay. I mean, that's that's compatible with ECMO life. So that combined with tunnel vision, 'cause I'm sure they did a whole bunch of echoes after that. I mean people get an echo for nothing these days in the in the ICU. So I'm sure this patient got a bunch of echoes in the in the ICU. And I don't think it it was discovered right away. I think they languished for like a week or something or nine days, and then eventually someone picked it up. Well it was so yeah, I think the definition of tunnel vision.

Anish Koka MD: exactly this anchoring television where you think X is going on and not entertaining other possibilities. What happened in this particular case? the other thing to mention is is that while this patient was doing very badly over over the course of the week or so that they were at the initial health system, palliative care got involved. and what and so can go through so you know the of course a lot of the language on online was surgeon, does terrible thing and then tries to harvest her organs. can you can you talk about why that is like a complete improbability and maybe in your unit how how how it is palliative care if they get involved, how they do get involved? Is that something you decide on or

George Tolis MD: well I've seen it done in several hospital systems in different ways. I have to say that we're very fortunate in our current system, that we have a great relationship with that service. And all these calls are physician initiated.

Anish Koka MD: Yeah.

George Tolis MD: I have heard of and witnessed other places where the you know, the end of life care, whatever you want to call it, the palliative care or, whatever name they use, are automatically involved without system involvement, without physician involvement. And I think that's the wrong way to do it. I don't know what system they had there, but the result could have been disastrous. And obviously the optics are terrible for a family to be told that we're gonna harvest organs and then to be told, well, we found out that the valve's upside down or we're gonna do an operation. Hopefully the ten or twelve days of ECMO is not gonna turn out to be fatal. And I don't think it was. I think the patient did well. it's just a horrible situation in multiple levels.

Anish Koka MD: But it's it's Would you say it's inordinately rare for an acute complication in a young, otherwise healthy person? You're not talking about somebody who's had endocarditis three times and you've replaced their vowel three times and they're now, doing extremely badly and they're in multi-organ failure. This is a thirteen-year-old girl who had procedure done a complication, it's been seven to ten days. the surgeon themselves are almost never going to Initiate that in a case like this, right?

George Tolis MD: again, I don't know the details of this case, but I would personally never initiate that on a seventeen year old. I try to transplant them if I thought the heart was dead.

Anish Koka MD: Right.

George Tolis MD: I'm thinking of, these services for older people that, may, have a stroke or have a sort of non meaningful life, months

Anthony Digiorgio MD: Okay.

George Tolis MD: later in a nursing home with a peg and tracheostomy kind of thing, on dialysis. Right. The bottom.

Anthony Digiorgio MD: Yeah, th those are those are my traumatic brain injury patients a lot of times, unfortunately.

George Tolis MD: Yeah, but again I think that has to be physician initiated. I don't think it should be institution initiated because Absolutely we are the we are the ones that saw the patient in the office. We are the ones that heard the patient in the family tell us that they want everything done. And I think that we are better placed to decide along with the family what is the right thing to do, not an external group of people that basically consult it themselves and because of a protocol that after seven days in the ICU you need to consult you know, they need to see all the patients. I don't think that's a that's a good way to do it. And thankfully that's not what we what we do in my institution.

Anthony Digiorgio MD: Okay, I want to circle back on something you had mentioned earlier about how doctors are so venomous to this surgeon. one thing I see doctors often accused of is covering for each other. you know, there's a lot of accusations of medical staff hiding negligence from lawsuits or from patients. and this is just, things I think you encounter on the lay media. Would you say just in general, are doctors Do doctors tend to cover for one another or do you think that they're pretty quick to call out their colleagues when things are going wrong? I mean of course, you the the famous one for neurosurgery is Dr. Dunch, Dr. Death, who was going around Texas killing people and it seemed that the doctors really tried to bring this to the attention of the medical board. so do you think that doctors are around going around covering up for one another?

George Tolis MD: well I think that doctors support each other for the most part in the hospital, but in social media I'm extremely disappointed in what I see and I just think it's a horrible environment in social media. It's people tend to misbehave behind a keyboard much more so than they dare to misbehave in person.

Anthony Digiorgio MD: Yeah, I think it helps if people have their real name or the the blue check on on Twitter. I think they're maybe a little bit more polite. Although not always, yeah. Not always.

George Tolis MD: be honest with you. I've had people call me in my home at two in the morning and threaten me and all that stuff. And we got families too. it's very sad. I mean they must, lead very, very sad lives for someone to do that.

Anish Koka MD: Alright, so th this case did have a happy ending. The patient was transferred to another in institution and again was stabilizing on ECMO needed a CAT scan for some other reason, and the CAT scan is what ultimately pinpointed the fact that the valve had been placed upside down. The valve was then the patient went back to the operating room and survived and, left hospital. There's now a lawsuit ongoing which is which is where this kind of came to light. I thought we would do some reader comments. I got some comments from from Dr. Tollis's last last appearance from a cardiac surgeon. and so I'll I'll read it, Dr. Tolis. I'm a cardiac surgeon and scientist. I run a lab, do some of the most complex cases on earth. I've pioneered several new high risk robotic operative categories. just because he hasn't innovated doesn't mean innovation is hurting the specialty. many of us feel an urgent need to innovate to continue to provide the benefits of cardiac surgery to patients in ways that are more acceptable to them. I think this was in response to the discussion about the rise of certain procedures like minimally invasive cardiac surgical cases that I guess the reader felt that you were poo-pooing a little bit as not really the these aren't really advancing the field. so your thoughts on on what what this esteemed colleague of yours thought?

George Tolis MD: Yeah, well I don't think minimal invasive mitral surgery is advancing the field. I think that the most important thing with mitral surgery, mitral repair surgery, I assume he means, is is to provide the best possible long term outcome for the patient. I don't think this is I'm I'm certainly not a mitral expert like other people are, but I would think that the the most prominent mitral surgeon in this country is David Adams from New York Sinai, who's also someone that I that I work with when I was a fellow. I worked with Dr. Greep in aortic surgery, but he was the chairman of the department. And he is probably the busiest mitral surgeon in the country, if not the world, and he does his operations through a media astronomy. I don't think anyone can blame Dr. Adams for not having innovated. He has written books about mitral surgery, published about it, and like I said, is the most famous mitral surgeon. So for someone who likes to do robotic surgery to tell me that I'm poo-pooing on these techniques because I don't believe in them, yeah, I think it's a little bit extreme. People want to do them and they get good outcomes by all means, they should. But if they claim that by doing so they can compete with someone who does a catheter procedure, I think that's a little bit of a pipe dream. you're not gonna compete with a catheter procedure. The way you're gonna compete with a catheter procedure is with a one once then done procedure versus repeat visits to the cath lab. And in my opinion the best way to do that is through a mediastronomy. That's all.

Anish Koka MD: The yeah, i it was interesting the comment about should we should we not give the people what they want? Because if what people want, regardless of what

George Tolis MD: No, I think our job is to advise I didn't give my kids what they wanted. if they did, I think they would have ended up with a syringe in their arm at some point. and all three of them have done very well. So, if my kids could report me to DHS and then DHS came to the house for an interview, they would have been here a lot. 'Cause, they asked me for a lot of things and I didn't give them to them and hopefully one day they'll be They'll thank me for that. But no, I strongly disagree with giving the patients what they want. We should advise the patients what is what we think is best for them, not what is best for our practice and for us to compete with a guy next door who does something different. we should advise the patient we should advise the patients to do what is best for them. And if we think that that is robotic mitral, then we should tell them that they should have a robotic mitral. If we think it's a stronotomy, Michael, we should tell them to have a stronotomy. If we think it's no surgery, we should tell them to have no surgery. But our advice to the patient should not be based on what they want to do. It should be based on what is best for them. And that's why they come to us.

Anthony Digiorgio MD: we get this in the spine world a good amount. patients will be told they need a fusion, they'll seek out some other doctor that maybe does like a artificial disc replacement, and a lot of times this isn't indicated. And I'm very sympathetic to that point that it really is about having a conversation while you believe that procedure is not best for that patient. I think disc replacement surgery is great when it's indicated. It's a very narrow indication. but most of the time most patients are actually gonna do better with a spinal fusion. but it's it's not about being paternal. and saying no, you I think you're totally right when you phrase it as that you have to advise the patient and really tell them your reasoning and your rationale and if they still want to make their decision and go with someone else who's gonna do a different procedure, ultimately that's their choice.

George Tolis MD: Right. And I think it's a little bit I'm not talking about the person that wrote that comment, but I think it's a little a little bit hypocritical for surgeons to say that, you know, some of us don't innovate when we concentrate on the things that we think add years of life to a patient. For example, you know, the national STS average for bilateral mammary arteries in cabbage, I think is six or seven percent. And many of us that believe in bilateral mammary arteries use them more than 50% of the time. I think this practice adds years of life after the first decade to patients that have coronary bypass. Is it innovation? Well, I I'm not I'm not sure I'd call it innovation because it's been done for a long time. Yet there's a lot of people that don't do it. So is it more important for mitral expert to do a robotic mitral on an eighty year old versus having a stronotomy replacement at eighty when the same surgeon as a second case uses a single mammary artery for a forty five year old. Well I think that's a little bit hypocritical.

Anish Koka MD: Anthony, do you think this represents a problem with our competitive, capitalistic mode of doing things? I mean, competition is supposed to be good. It's supposed to drive down prices, but in this particular case, competition may promote someone selling, something different, something that is like optically better, in this case, smaller surgery or, you know, etcetera, that not may not be necessarily better for for the patient. and of course, because of information asymmetry, which is unique in medicine, not in anything else, I'm being I'm being sarcastic, the patients are the ones that suffer. What what what say you to that?

Anthony Digiorgio MD: Well no, I mean this is no different than you go to your mechanic. You know, get your oil changed and now they're trying to upsell you on a new transmission, and you really don't know if that's needed or not. And the competition helps keep people honest, right? If a mechanic gets a reputation of being dishonest, or plumber, or an electrician, and that will eventually come back to them. And I think the same will eventually go for surgeons. It's not perfect. There's no system that will prevent every single patient from making the wrong choice every single time. All we can do is try to empower patients and have a competitive marketplace that allows these ideas to come up in in a distributed fashion. If you have some central planner saying that only procedure X is indicated, well you're never gonna get innovation. and sometimes you do need that innovation. and so I think taking it to some central authority to determine what is best for every patient in every discrete situation is not the way to do it. Again, going back to the spine world, there there are cases where a disc replacement is absolutely indicated and probably a better surgery for that patient than a spinal fusion. but if you had some central planner say you can only do spinal fusions, then you'd never have the innovation of disc replacement. And no central planner could know all that new. nuance enough to make that decision. There's no AI algorithm that can do that. You know, it's really I I make that decision with patients by talking to them, by personally evaluating their goals, what they're what they want as a result from this, what their spine looks like on their X-ray, on their MRI, on their CT scan, what their symptoms are. And there's so much that goes into that that I don't think you could ever centralize that decision. So it really has to be this distributed knowledge. This is again where you know Hayek ends up being right, once again.

George Tolis MD: Well and the other thing is I think it's very important when you decide whether a procedure is sort of as good as it's advertised to be is you have to look at history and you have to see what has happened in the past and what happened to surgeons that dismiss certain operations. For example, cardiac surgeons in the 60s and 70s were either congenital surgeons or valve surgeons. They're doing AVRs, they're doing MBRs. So in the late 60s, early 70s, you know, coronary bypass became a thing. And There are surgeons that said, you know, these things will not stay open, they're too small, the veins are too small and does it's not gonna make a difference. Well, you know, that didn't a that didn't age very well. And there are some people that never learned how to do coronary bypass from that era. And I remember them in the late eighties they were like doing pacemakers because they stopped being cardiac surgeons because they didn't jump into the coronary wagon. Now, if coronary bypass was a fad and it only worked in expert hands and centers of excellence, it would have died out. Well it didn't. Coronary bypass, which is the toughest operation that we do, technically, is what it is today, and it has survived stents, it has survived statins, it has survived angioplasty, and so on and so forth. So coronary bypass is a procedure that added years of life to patients, and it was reproducible. Now take the Ross procedure that's really hot today, for aortic valve replacement, and there's Ross summits and there's Ross centers of excellence. the first Ross was done in the late 60s. This is not a new procedure. And the Ross has seen sort of an undulating up and down pattern, and this is the second sort of regeneration of the Ross wave that I've seen in my career, the first one being the early 2000s, and everything is about Ross now. If you're not doing a ROS on a on a 45-year-old who has AS, then you're not a good surgeon. Well, that let's kind of go down again. And the thing with a ROS is that no matter what people tell you, they develop aortic insufficiency, number one. And number two, you do need to deal with that pulmonary homograft at some point. So is it a bad operation? Absolutely not. Are there indications for it? Of course there are. But should it be done by people that do a lot of Rosses? Yes, absolutely. But it's not the answer to all AVRs and is and you know and young people and you know mechanical valves are gonna go away. We've we've heard that before. So mitral valve repair, there are people that said that mitral valve repair was a sham when Carpantia introduced that procedure. In Boston The chief of Mass General in the late eighties, early nineties, famous surgeons, said that it was a sham. Well, they didn't age very well. And what's his name? Larry Cohn at the Brigham, you know, was eating Mass General's lunch for the next 20 years because he became the referral center for mitral repair in the Northeast. So you can track what mistakes have been made in the past and avoid sort of inflammatory statements. is I guess what I would say.

Anthony Digiorgio MD: I think part of the

George Tolis MD: Lap Coley's another one. You know, Hopkins, Doctor Cameron on Hopkins said that Lap Coley was a sham and that they're going to injure the bile duct. And the University of Baltimore started doing Lap Coleys and Hopkins was doing open collisions and, you know, they lost a lot of ground in the early nineties. Why? Because Lap Coli is a great operation, very reproducible operation. So history teaches a lot of lessons that some people don't want to learn.

Anthony Digiorgio MD: With procedures it's difficult though because we you know as surgeons we operate a lot of time for twenty, thirty, forty year outcome. and we we really don't have this long term data. I understand probably about ten percent of the stuff you're talking about, Dr. Tollis, because for me the only ventricles that exist are in the brain. but i when it comes to the surgeons that we do, again, you going back to spine and brain, if we're doing these on younger patients, if somebody's asking me what's the 30 or 40 year outcome difference between doing a disc replacement and a fusion, I don't have that data. Nobody has that data, right? And the data we do have are on technology that's, 10 years old. If it's a 10-year outcome data, and then that technology we're not using anymore. And so really this information asymmetry comes to the physicians as well, is that We are probably pretty confident in our techniques. I think we're usually making the right call, but we don't have thirty or forty year outcome data. And it's impossible to get that data to make the decision now because in thirty or forty years the technology's gonna be so different and the procedures are gonna be so different that the the procedure you're studying is gonna be extinct and you're gonna have new procedures that you're gonna want forty year outcome data. So we are gonna perpetually be in sort of this fog of war when it comes to choosing the right procedures for our patients.

George Tolis MD: I agree with you a hundred percent. And we get incentivized to do operations that look good in 30 days in surgery. patients want things that get them out of bed the next day. even if that is not the best thing for them. you know, if you're a roofer and you come in and a roof's about to collapse and someone tells you you just want you to patch it, I don't think you're a good roofer, you just patch it. You gotta explain to that homeowner that you gotta do the real thing. And I'm not entirely convinced that we do that very well sometimes because of personal interests or because of of of outside forces. Like I said, you know, we get judged based on what happens in thirty days. I think that's a major reason why we don't use bilateral mammaries in young patients as much as we should. and I think it's very good to be introspective when you're a when you're a surgeon, to The most important thing is I think to admit to yourself your insecurities. Why am I not doing this? Why am I arguing against this? And first of all, be honest with yourself. am I not doing this because I don't think I'm good at it, but it's good enough and someone else should do it, or am I not doing it because I wouldn't want my family member to have this done? I think that is the best question that you can ask yourself before you dismiss a you know in operation. And personally, I mean I'm fifty seven. If I needed an A V R now I'd tell someone to put a mechanical valve in me and never have a redo again. and I would take my cumadin every day. I'd buy the machine and I'd check the The finger stick and that's fine, you know. you know, the first time I took a pill in my life was when I was 39. I started taking crestor because my cholesterol was high. And I was pissed, because up until then I'd wake up, brush my teeth, and go do what I gotta do. And I gotta wake up take a pill. Well, now you know I've added aspirin too. And but you just gotta Admit to yourself that that's what's going to happen and move on. So I think cumadin is very similar to that. You know, you want one operation and just be done with it and not worry about homographs and AI and all that stuff. But again, other people think differently. Your job as a doctor is to understand what your patient's needs are, explain to them the theory behind it and let them make a decision.

Anish Koka MD: Well the well so I yeah I was actually gonna ask something else, but now you've raised a couple of interesting things. One the paradigm of taking a fifty seven year old and doing a bio AVR with the understanding that they may get Tavers after that and save astronomy. Wha what are your thoughts on that?

George Tolis MD: Well, so let's just say that I'm seeing a fifty seven year old who needs an A V R. The wrong thing to do, I think, is to tell them you don't want a mechanical valve. You know, we'll put a bioprosthetic valve, and then in thirteen years, ten years, you're gonna get a tabra, you'll be all set. Well, the vast majority of valve valve tabras that get turned down, they get turned down because of coronary heights, not because of the size of the of the aortic valve. So if you're gonna make that statement. You can only make that statement after you look at a CT a Taver CT scan after the patient's had the AVR. So the ship has sailed. So the correct way to discuss that with a patient is yes, there is a chance that you might be able to get that valve addressed again, not if, but when it fails. and it might happen with a TAVER, but you might need another operation, number one. Number two, the risk of the valve to valve taverna is this, the risk of the reoperation, surgical reoperation is this. What's very important that we don't discuss with patients, and I think we should, is that it's not only that you're facing another operation, but your heart is facing another cycle of aortic stenosis. And it's already faced that once, it's going to face it again. The hearts that face two cycles of aortic stenosis, even worse, a cycle of aortic stenosis followed by a cycle of aortic insufficiency, are much weaker when you take them back the second time. So it's not as simple as you're gonna have another operation like you did before, and then you're gonna buy another 17 years. These are all things that we need to discuss with patients. Have our feasibility and the burden on the heart. to sustain another cycle of a valve failure.

Anish Koka MD: and then the part where you talked about the reason why we don't do bilateral internal memories or why surgeons don't do that is because of thirty day outcomes. Can you clarify and explain that?

George Tolis MD: Sure, there's not very good data, but fairly decent data that the risk of a sternal wound infection is higher, of sternal dehiscence and a wound infection, when you devascularize the sternum even more than taking one mammary by taking two mammaries. So in very obese patients and diabetic patients, in poorly controlled, I should say, diabetic patients, that risk is probably real. So If someone does a if a surgeon does a bypass and the patient gets a wound infection, then that's an STS metric and we look at the three stars and all that stuff. So people don't want to deal with that and they avoid doing bilateral mammaries on diabetics, avoid doing them on obese patients, avoid doing them, period. I've been a proponent of bilateral mammaries for the last fifteen years. I personally have not seen an a difference in wound complications with two mammaries versus one. the data that claims that there is is not very good data, but it's there. It's Japanese data mostly. about the skeletonized mammaries and I don't think it's contraindication in terms of guidelines. I should know that probably, but I don't think it is. but people avoid it because they don't want to get in trouble and they don't want to deal with a 30 day negative outcome that would affect in a negative way the the results of their program.

Anish Koka MD: I see. Even though, bilateral IMAs may b have better long term durability for most people, just that slightly up that slight uptick in thirty day outcomes is

George Tolis MD: We do have Cleveland clinic data that shows that after the first decade the right memory adds a survival benefit. And it does make sense that it does, because a lima does. Now it may not be as pronounced a benefit as in the lima, because the LAD is, you know, the biggest vessel with the biggest distribution area, but it can be worse. It can only be better. Well

Anish Koka MD: And a question for both of you, and then we'll we'll end here because we've taken up too much of both of your times, is

George Tolis MD: I have plenty of time here, no worries.

Anish Koka MD: the model of inpatient payment is where you get a certain amount for a certain procedure. a CPT code, the CPT code for a vowel replacement, CPT code for a spinal fusion. And so you're getting the hospital is getting a certain amount for that, right? how does that Payment structure, which is this prospective payment system, which is different than the cost plus system that used to exist before, prior, in in an era before hospitals would just say this is our cost, and the payers are pay plays pay some percent over that. now the model is you you're getting paid a certain amount. How does that set amount of payment affect the use of novel devices in the procedures that you both are doing. does it not make it less likely for innovation to happen? Because if you've got a valve, say an aortic valve that costs fifteen hundred dollars, why put in a seven thousand dollar valve?

George Tolis MD: if you have proof that the seven thousand valve is better, then you should use it. and the hospital should absorb that cost. We don't have any proof that the seven thousand dollar valve is better than the four thousand dollar valve. but industry has done a great job to convince people that there might be a benefit down the road. they're very good. I mean they're

Anish Koka MD: But they're but they're convincing surgeons because certainly the that's the interesting thing, right? It's not the admins the admins want you to use the thousand dollar valve.

George Tolis MD: Well, it's the surgeons that are being our institution the admins won't tell you what to use what to use. and in my previous jobs as well. I've never worked in a place where they told us use this valve because it's cheaper. we've had discussions when they said, listen, you know, this hemostatic agent that showed up all of a sudden is like a thousand dollars a pop. But not about valves that but I mean, I personally don't use the expensive valve because I think there's no long-term data that exists for that valve, whereas there's excellent long-term data for the other it's not cheap the other one, but the other one's more expensive. So again, I think it comes down to you as a physician doing to a patient what you want done on your mother.

Anthony Digiorgio MD: Yeah. I I agree with that. They get paid based on the DRG.

Anish Koka MD: DRG, D sorry.

Anthony Digiorgio MD: Which is a diagnosis related group, which is different than the CPT. And so if you get really into it, there are diagnosis-related groups that are carved out around certain types of technology. so if you do procedure X with technology A, it falls into a DRG that covers the cost of that. That is obviously heavily driven by lobbying efforts within CMS by industry, because they come up with a device that maybe adds $8,000, $10,000 to a surgery. and they can then go to CMS and get a new DRG written that would be broad enough to include their device and s and up the price of that. If it is something that's done in a physician office, the price of the device is actually priced in when they do the valuation for the facility fee RVU payment. so they use essentially sort of a cost plus model, but they look at receipts and see how much n the technology costs at the time and then value it there. So it is sort of priced in. but that is correct that you should want to use what's best for your patient. and the hospital should probably let the surgeon. there are hospitals that that don't let surgeons use what they want because they control costs or they have special negotiations. There's some hospitals that limit it to one vendor. Again, in the spine world, you know, probably fifty, sixty different vendors you can get for, you know, your spinal instrumentation. And some hospitals will limit it to one or two vendors. And try to keep out the the higher cost ones. some hospitals let you let you use whatever you want. But you should want to use what you think is going to get the best outcome as the surgeon. and then the other thing that can go into it is if you become an outlier payment, if the cost to a certain procedure goes a certain amount above what the DRG is, it actually goes into outlier payments and goes back into that cost plus model reimbursement. And so at some point. it actually becomes advantageous to be more expensive because you're exiting the DRG world and going back into cost plus and if you go to cost plus the more you spend, the more you get. and so there's sort of an irony there.

Anish Koka MD: Yeah, sorry, I totally brain farted that. on the outpatient office side, when you do procedures, there's this CPT code and that's valued as Anthony's saying. Of course, the issue is that as a physician have the are incentivized to because you're getting paid the same amount for a certain device. Say say you're implanting some device in the office, you're getting paid the same amount for that thing, regardless of what device it is you implant. Now each device that you implant has a different cost. there may be something that has a battery that's like a year less. And you end up implanting, you know, if you implant that device, you get paid $500, that's a cheaper device. So that and sorry if it's so yes, not CBT in the hot in the hospital, it's it's DR DRG based. Is it just the idea that admins havn haven't gotten to the point where they say, hey, they're not micromanaging what exactly you're choosing to do. And is and is it because of this this kind of relief valve of well if he does choose some hyper expensive thing and it's a massive outlayer payment, then there's still going to be payment regardless.

Anthony Digiorgio MD: No, I think there are admins that will try to control what the surgeons do. And there's some that, you know, say we brought this surgeon in to 'cause he's the best and we're gonna let him use whatever equipment he wants because we're still gonna make positive revenue, despite how much expensive stuff he uses.

Anish Koka MD: Dr. Tillis, does it the idea that there are valves that get on the scene that are able to be used in patients without strong data to suggest they're much more effective, do you think that's kind of a problem on the regulatory side in terms of how it is we're allowing some of these devices to get on scene and why would you say surgeons why are they susceptible to say implanting the newer fancier valve?

George Tolis MD: I'm not sure I know the answer to the question because I'm not one of them. but I know that I'm the minority. And I know that people in the industry don't like me because of that. Well, maybe they don't like me for other reasons too. Like people write on on Twitter a whole bunch of like stuff. I hope my kids don't see it, but it's I think it's the path of least resistance for people to just say, you know what, I just don't want to deal with this. They're coming in, they want me to use this, I'm gonna use it. if it's something that's better, yes. Like I use a product called tachyle, which is a sealant that you put on the surface of anything and it stops the bleeding. That thing is just beautiful. That thing is I mean they should they should make that an antidepressant, you know. That thing is like it it it's the best thing ever discovered. In cardiac surgery. And I think it's expensive, but I do use it because it works so well. If someone tells you that a valve in the lab lasted for five billion cycles versus 4.5 And I'm gonna sell it for twice the price because it might have a survival advantage when the already existing valve has an 87% freedom of reoperation at 17 years. That for me is a little bit of a stretch, and I'm not gonna implant that valve for twice the cost. And I don't think I'm doing a worse operation. As a matter of fact, when I talk to patients in the office and I tell them there are two options. Both valves are made by the same company. The first valve has been around since the 90s and it has an 87% freedom of free operation of 17 years. The second valve might be better than that, but we don't know. It's only been out for 10 years. 100% of patients say, I want the first valve. 100% of them. So, and I think that is true informed consent. And it does take an extra five minutes to discuss this with a patient, but I think it's important to discuss it. And I don't try to bias them one way or another, because I've no issue using the other valve. If someone feels more comfortable using the new valve or they're, you know, they're up for an adventure or whatever it is, then fine. That's great. But I've presented it this way to patients. A hundred percent of them have said I want the one that's been around for since the nineties.

Anthony Digiorgio MD: we get no money from tachyle. but I actually use it too. I think it's great it it works great for spinal fluid leaks.

George Tolis MD: It's the best.

Anthony Digiorgio MD: It it really is. But to that point, so if anyone is wondering if we get money from Tacasil, the nice thing about being a doctor two things is one is that you can look up all of our conflicts of interest on the Sunshine Act. So if patients are listening to this and they're worried that we get some sort of kickback or that we are motivated financially to use one product over the other, they're actually very strong anti-kickback laws. So there's the Sunshine Act where can look up any one of the three of us and see what sort of money we've gotten from industry, even if they bought a a lunch, you know, that will show up on the Sunshine Act page. and number two is that it's illegal for us to get kickbacks if so if you own IP on some new device and you are implanting that in your own patients, you cannot get paid for the IP and the the patients that you are treating with that device. So doctors are are generally free of conflict of interest from this. And so I do want to reassure patients.

George Tolis MD: I have no disclosures. I don't know if I was supposed to start that way, but I have

Anthony Digiorgio MD: This is not C E

George Tolis MD: Get zero money from industry. Absolutely zero. And actually, if you look at the website, I found out someone told me about the website where people list what they make. they have me listed as having taken I think it like sixty dollars from a medical company once, and I suspect that they must have invited me to a dinner and I didn't go. So that's most likely what it is. But I I have zero relationship with industry and I think that's great because I use the products that I want to use with no pressure.

Anish Koka MD: Well that is a topic for another day. for instance, take GLP ones, right? As a cardiologist, G L P ones are very interesting in terms of weight loss, injectables. It was primarily in the endocrine space actually, and then then slowly demand was so much and so many people are using it for so many different reasons. But, whatever number of years ago, it seemed pretty obvious that, you know, cardiologists that are managing patients' blood pressure, cholesterol, a variety of different things are should very well should be prescribing GLP1s. how can it not be a com you know part of what you're doing as a general preventative cardiologist? back in COVID times, right before COVID times about being one of the f one of the folks who was prescribing a f a reasonable amount of GLP1s as a cardiologist. and they're like, would you mind talking to other cardiologists about how you're doing it and making them feel more comfortable about it. It's exactly what industry does, right? Industry takes folks that are you know one is manufactured. Yeah, right. And so so I went and spoke and talked about, you know, how how it I gave GLP ones to try to convince other folks, other cardiologists say, Hey, we should be giving GLP ones. I now I didn't want to do that for free, so I I did take some dollars for that. But you the the amounts are like so relatively trivial. So but no, it gave me a perspective into okay, not every dollar necessarily translates to to conflict necessarily. because if you're gonna take this whole notion to some extent, it's like, okay, then I should be spending my nights telling other cardiologists about, you know, using GLP ones to make them more comfortable and doing that, you know, for for free. It's like, well, I th you know my time is valuable, so anyhow, we that'll be a topic for another day. Dr. Toles, this has been a fantastic another hour and a half. Thank you for thank you as useful for the time. We covered a wide variety of topics.

George Tolis MD: Yeah, it was very good. We should do it again for sure.

Anish Koka MD: Absolutely, absolutely. I look forward to the comments. I gotta find some other folks in the CT surgery community as well. Maybe we'll have them on along with you the next time. That'll be fantastic. Yeah, yeah, that'll be great. So Dr. Giorgio, you are traveling somewhere. Thank you for logging on from wherever it is you are. Where are you by the way?

Anthony Digiorgio MD: Washington D C remind our listeners to please listen to

Anish Koka MD: Yes, yes, absolutely. Alrighty. Thanks so much, folks. Alright, we will see you guys next week. Thanks.