Prof. Gonzalo Varela: it is very important to build our hospital patient-centered institutions

Preface

“If you want to be a surgeon, first be a good doctor—Prof. Carlos M.G. Duran”, Prof. Gonzalo Varela (Figure 1) recalled his mentor’s words when looking back at his career, “I still remember his words, and I’ve just tried hard for 42 years”.

Figure 1 Professor Gonzalo Varela.

Yes, we can see, keeping it in mind as a motto, Prof. Varela indeed has practiced it with action along his path of medicine.

Since be appointed chief of Thoracic Surgery in 1994, Prof. Varela had been serving for Salamanca University Hospital for over 20 years until end of 2015, with special concern on patient’s safety. One of the aspects he is most proud of is having improved the quality of all surgical processes to decrease the rate of adverse events without excluding from surgery high-risk cases if surgical therapy was considered the best therapeutic option.

When asked about his opinions on big challenges we are facing in hospitals, Prof. Varela pointed out the need and importance to build patient-centered institutions.

“Patients must be involved in decision-making”, he said “at least in my experience, we have been working centered in doctors’ needs or in developing medical services but not much in patients. We need to make clinical decisions according to patients’ preferences, values and needs.”

To know more, please refer to the following in-depth interview with Prof. Varela by AME.

Personal experiences

JHMHP: As we know, you have a long history with the Salamanca University Hospital (SUH). What would you say are some of the most noticeable changes that have happened in the hospital over these years, and what changes we could expect to see in the next five to ten years?

Prof. Varela: Salamanca University Hospital—an academic hospital owned by the Castilla y León Public Health System—started in the 80’s as a single building devoted to teaching undergraduates and focused in Internal Medicine, General Surgery and Orthopedics. Nowadays, we have five buildings in three different locations and all medical and surgical specialties. The medical staff is composed by around 600 fully trained doctors and 200 more in training. The center is offering specialized care to a population of more than 1.5 million people in some specialties. For doing so, we have been obliged to offer new positions to more specialized doctors, and to invest millions in up to date diagnostic and therapeutic technology. Currently, the new hospital buildings are close to be finished (the expected opening date is December 2018) offering more space for patients’ single rooms and more surgical theatres, including hybrid ones equipped with advanced medical imaging devices and allowing to implement more minimally-invasive procedures. Our wish is offering more and more patient-centered care focused in out-patient and fast-track facilities.

JHMHP: Over the years as the chief of the Thoracic Surgery Service in SUH, what challenges have you encountered when you manage the service? What aspects are you most proud of when introducing the service to experts from outside of Spain?

Prof. Varela: I was appointed chief of Thoracic Surgery in 1994 and stayed in charge up to the end of 2015. In fact, Dr. Marcelo Jimenez and myself founded the unit and worked with the help of one of the best anesthetists I have ever met Dr. Esther del Barrio and a nursing staff for 5 years. At the beginning we had to work from 7:30 am. up to around 9 pm. Five days a week and remained on call on weekends. We had the opportunity of training a fantastic nursing and physiotherapy staff and implementing all kinds of thoracic procedures—except lung transplant, which is not currently performed in Castilla y León—including airways surgery, complex chest wall reconstruction procedures, any kind of bronchoplastic resections and VATS lung resection. From the beginning we were committed to continuing quality improvement and invested a lot of time and money in having ad-hoc electronic databases and management systems to control patients’ outcomes along time. From its beginning we contributed to the European Society of Thoracic Surgeons (ESTS) database and organized and participated in Spanish and European benchmarking activities. Along my career I’ve been always focused on patient’s safety. The aspect I’m prouder of is having improved the quality of all surgical processes to decrease the rate of adverse events without excluding from surgery high-risk cases if surgical therapy was considered the best therapeutic option. Currently, the 30-day mortality of VATS lobectomy in Salamanca—as in many other hospitals in the world—is around 0.5%. Besides, we have facilitated the access to high-quality thoracic procedures to a dispersed population in a large area of land thanks to the latest technology in communication.

JHMHP: Except from your work in SUH, you’ve also held multiple senior administrative positions in many societies, including ESTS, Spanish Society of Pneumology and Thoracic Surgery, etc. Could you briefly introduce your work scope and some of the memorable moments in your time as the president of 2016 ESTS?

Prof. Varela: I became the president of the ESTS as the result of a series of circumstances. I was ending my term as the ESTS editor and working together with other councilors in constructing the ESTS database and quality accreditation system and involved in teaching at the ESTS academy. The rest of the councilors I was working with were necessary in their positions and I think I was the best option for the presidency. According to the ESTS constitution, the president is appointed by the members at the General Assembly to serve until the end of the Annual Meeting in the following year. During my presidency I tried to represent the society the best I could. Maybe one of the most interesting activities was having contacts with colleagues from different parts of the world to promote an international database of thoracic procedures aimed to establishing internationally accepted quality standards. From a personal point of view, I learned how to improve my personal practice from thoracic surgeons in China, Russia, Brazil, and many other countries I haven’t had the opportunity to meet before. As I have said, throughout the years the ESTS activities have been focused in improving surgical quality and offering resources to thoracic surgeons for advanced professional education.

JHMHP: In the ESTS presidential address, you shared the stories behind about how you dreamed to be a music player, a knight, a family physician, and then a surgeon. Would you like to further elaborate what took you to the path of thoracic surgery?

Prof. Varela: Following family roots, I should have taken a road to become an artist, but I admired our family doctor and wanted to follow his steps; he was a good clinician and, mostly, a nice human being empathizing with his patients. Besides, at an early age I had the opportunity of reading the famous novel “The Citadel”, by Archibald Joseph Cronin, and decided I wanted to become that kind of a physician too: knowledgeable, skilled, innovative, responsible and empathic. Curiously, after my first contact with the surgical world I changed my mind to surgery. I realized that a surgeon is just a doctor with technical abilities to operate on patients, but his clinical skills and medical knowledge must be comparable to a good internist. I was encouraged to apply for a position in Cardio-thoracic Surgery by Prof. Carlos M. G. Duran (recently passed away) who warned me against becoming just a technician. I still remember his words: “If you want to be a surgeon, first be a good doctor”. And I’ve just tried hard for 42 years.

JHMHP: With so many roles at once, how do you manage your time and maintain work-life balance?

Prof. Varela: Thanks to my wife, Isabel. We have formed a good team for many years. Together we have grown up five children which I consider has been the most valuable and rewarding task in my life. She has taught to me the true meaning of success.

Hospital management and policy

JHMHP: From your rich administrative experiences, what would you say is a common problem or challenge that you can see in hospitals?

Prof. Varela: I don’t know in depth many hospitals, but I have a good knowledge of my center after being the medical manager during the last period of my career. I have to say too that I have never practiced outside of a public health care system and that is probably biasing my view of what should be a hospital in the current days. One of the most important challenges we are facing today is making our hospitals patient-centered institutions. At least in my experience, we have been working centered in doctors’ needs or in developing medical services but not much in patients. The second challenge is making health care sustainable.

JHMHP: Can you explain the meaning of patient-centered care?

Prof. Varela: Centering care in patients means that clinical decisions must be taken according to patients’ preferences, values and needs. Patients must be involved in decision-making. For doing so, the hospital must progress in establishing ways to improving communication with patients and accurate and understandable information must be provided regarding clinical status, prognosis and therapy. Health care must be facilitated coordinating all diagnostic and therapeutic activities at all levels, including primary and home nursing care. Families must be also involved to decrease patient’s fear to disease and therapies.

JHMHP: Don’t you believe that current health care is sustainable?

Prof. Varela: The rate of senior citizens is rapidly growing in all civilised countries. Currently, a rather high percent of our population is having more than one chronic condition needing care. We must focus on preventive medicine and self-care. Health care systems centered in implementing high technology hospitals and complex surgical procedures cannot survive longer. A cultural shift is needed not only for patients but mainly for professionals who must accept that complex diagnostic techniques or therapies should be concentrated in a few hospitals around the country facilitating easy access to patients. Care providers should be rewarded according to their efficient and evidence-based use of public health resources.

JHMHP: What do you think are some pivotal skills that hospital administrators should possess?

Prof. Varela: As medical managers we must have always in mind that we are working to improve patients’ health, not to save money. Accurate information is needed to evaluate diseases prevalence and patients’ outcomes to distribute resources in an equitable and judicious way. Managers need to be skilled in exploding all the information big databases hide inside them.

We must spend only a minor part of our time in the office and participate in the hospital daily living visiting wards, diagnostic and outpatient facilities, and surgical areas to identify deficiencies and applying the correct solutions. Daily contact is also required with our colleagues managing primary care assistance to provide a continuum after patients discharge. If we know every hospital corner, we are in a good position to get agreements between different specialists to coordinate care and to avoid duplicities in the caring process. We must be open to listening both professionals and patients’ needs and prepared for frustration since our work is sometimes under estimated or ignored.

JHMHP: How do you think your experiences as a clinical surgeon assist you to take on the hospital management role, or in the opposite way?

Prof. Varela: It is not easy answering this question. From a point of view, I can’t imagine a hospital medical manager without a solid clinical experience, ideally in the same hospital he or she is managing. The better you know your colleagues the better you understand their expectations and needs. On the other hand, when you are promoted to a management position, people are expecting that you’ll be able to solve all kind of problems encountered in daily practice. Obviously, that is not possible, and you must struggle to convince your colleagues that there is nothing magic inside the manager’s office to make things work. Depending on your previous areas of training and clinical practice you can also be prone to understand and facilitate more surgical or medical aspects of the hospital and you must be aware of it.

Advice for young generation

JHMHP: In your presidential address, you attached great importance to teaching youngsters the value of listening to the patients and carefully exploring them before making any clinical decisions. Would you like to share your philosophy of the training of your staffs? How do you evaluate their performance/standard?

Prof. Varela: I am convinced that talking to patients and exploring them will never be outdated. Clinical training is simultaneous to acquiring basic surgical skills at my former department. People visiting our offices were surprised because textbooks of internal medicine had a privileged place in our library. Residents were trained to register all clinical information and possible diagnosis before calling another specialist for consultation. We paid special attention to knowing the predictive values of diagnostic tests in our milieu and indicating them according to the pre-test probability of a diagnosis. Regarding surgical training, residents were obliged to perform a certain number of procedures on anatomical models before being allowed to real practice. That was especially useful for basic training in VATS lobectomy. Following an initiative of Dr. Jimenez, all residents performed at least 20 lobectomies on cardio-pulmonary blocks taken from pigs before assisting the surgeon in theatre.

JHMHP: As a successful thoracic surgeon, what would be your advice to younger generations (like younger physicians, nurses or students) in pursuing their dreams?

Prof. Varela: When I’m teaching youngsters, I’m frequently citing the motto of an advertisement for a gym I have found at the internet: If it’s not hurting it’s not working. Some people can make any kind of an effort just to have a nice body, regardless how much time or money they must spend, or muscle injuries they must suffer. To me, being able to cure people using own hands or having knowledge enough to find a solution in a complicated case or finding favorable outcomes in the population you are caring for is priceless. I always try to encourage newcomers to medical practice to love their profession and not feeling defeated in their dreams simply because professional practice is not always easy. When I’m looking back after 40 years of practice I realize that I’ve been living a fabulous experience.

Expert’s introduction

Dr. Varela was professor in Department of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain. He achieved his master’s degree in University of Navarra in 1975, PhD in Autonomous University of Madrid in 1986, and MSc, Health Care Management in University of Cantabria in 2001. He was the chief of the Thoracic Surgery Service in Salamanca University Hospital since 1994 and professor of Thoracic Surgery in Salamanca University Medical School since 2006.

Board certification:

• European Board of Thoracic and Cardiovascular Surgeons (FETCS), 1998.

Professional committees and boards:

• President of European Society of Thoracic Surgeons [2015];
• Associate Editor in European Journal of Cardio-Thoracic Surgery [2011–2014];
• Associate Editor-in-Chief in Annals of Translational Medicine (2015–present).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Hospital Management and Health Policy for the series “Meet the Experts: the Cutting Edge in Hospital Management”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jhmhp.2017.12.03). The series “Meet the Experts: the Cutting Edge in Hospital Management” was commissioned by the editorial office without any funding or sponsorship. Jessie S. Zhong reports that she is a full-time employee of AME publishing company (publisher of the journal). The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

(Interviewer: Jessie S. Zhong, JHMHP, jhmhp@amegroups.com)