April 3rd, 2011

The Cardiology Profession: At the Table or on the Menu?

Several Cardiology Fellows who are attending ACC.11 this week are blogging together on CardioExchange. The Fellows include Sandeep Mangalmurti, Hansie Mathelier, John Ryan (moderating and providing an outsider’s view from Chicago), Amit Shah, and Justin Vader. See the previous post in this series, and check back often to learn about the biggest buzz in New Orleans.

After a quiet day settling in yesterday, I was very excited to begin my first ever ACC national conference. So far, it has not disappointed. The day began with a rousing multimedia presentation and the national anthem; if only my regular fellowship days began with such a punch! The theme of the morning’s introductory remarks was not the science of cardiovascular disease, but rather the profession of cardiology and the broader social and policy context within which it operates. As someone who is just beginning his journey as a cardiologist, understanding this context is an essential element of a successful career.

The first major address of the introductory session was the Franz M. Groedel Presidential Plenary Lecture, delivered by Dr. James Orbinski, former international president of Doctors without Borders (Medecins Sans Frontieres). He recounted his experiences in Africa with AIDS patients, as well as victims of the Rwandan genocide. As one would expect, the focus was not on the details of their health care. Rather, Dr. Orbinski’s teaching point was that to truly help your patients, you must become engaged in the larger policy infrastructure that shapes the way you practice and the therapies you can offer. Of course, he is absolutely correct; physicians can never shut our exam room door and “just take care of our patients.”  In today’s environment, most of the decisions regarding that care will happen before the patient even sets foot in the clinic or hospital. This interdependence is particularly pronounced in developed countries with austere practice environments. Kindness and clinical skills are ineffectual without the medicines and other resources to provide care; only political involvement and advocacy can provide those resources, and providers must be part of that process.

Of course, the vast majority of those at ACC 2011 will never travel overseas with Medecins Sans Frontieres. However, we are still not off the hook, as emphasized by the next speaker, ACC President Dr. Ralph Brindis. His focus during his tenure as ACC President has been on professionalism, and for him, it is inextricably linked to being good stewards of the profession. We are one of the few professions that is allowed to regulate itself, a privilege we have earned through decades of dedication to values that transcend our financial and professional self interest. As our practice environment and resources become more austere (though hopefully not approaching those of developing nations!), we must continue to show why we continue to deserve that trust. In this turbulent time of health-care reform and need for cost effectiveness, change is inevitable. As cardiologists, we can help shape this change, before it shapes us. Or as Dr. Brindis put it, we can either be “at the table or on the menu.”

How does the profession of cardiology stay off the menu? Our contribution to this debate is our understanding of clinical medicine, and our access to data regarding outcomes, quality, and utilization. Neither the public nor public leaders have this skill set, and they need physicians to help them make sense of the growing sea of information on quality and cost effectiveness. We can help them by continuing to promulgate rigorous evidence-based guidelines, and publish accurate data on clinical outcomes and performance metrics.

Dr. Brindis found one regulatory mechanism worthy of particular mention: developing a culture of appropriate use. One particularly corrosive failure of cardiology is the growing perception that many in the field may be performing unnecessary tests or procedures merely for reimbursement. One recent episode of The Dr. Oz Show asserted that 50% of PCIs are unnecessary. The recent accusation against interventional cardiologists at St. Joseph’s Medical Center in Maryland does little to undermine that perception. The speaker also mentioned a recent JAMA article which asserted that more than 22% of ICD placements were non-evidence based. The accuracy of these assertions will continue to be debated by the experts, but all cardiologists have a role in helping to gather evidence and data to help answer to these questions. The continued development of utilization and practice pattern databases is yeoman’s work that we must all share, but where the profession may be falling short.

No discussion of the upcoming changes in cardiology would be complete without a discussion of the recently passed health-care bill (The Patient Protection and Affordable Care Act of 2010). I was eagerly anticipating the discussion today by Dr. Robert Kochner, a special assistant to President Obama, regarding the implications of this Act on the practice of cardiology. He was, unfortunately, unable to attend, but we still received an illuminating discussion of the topic from Dr. Brindis, Dr. Richard Kovacs (outgoing chair of the ACC Board of Governors), and Dr. Jim Fasules (Senior VP, Advocacy and Policy, ACC)  The contour of the debate continues to shift, and is currently dominated by the discussion of the country’s deficit burden, but the ACC’s legislative goals have remained constant: expanded access, maintenance of a private health-care system, improvement of quality of care, and payment reform. How and if the new legislation meets these goals remains to be seen; these questions will take years to answer. In the interim, the ACC continues to push for 3 major legislative changes (in additional to its baseline advocacy for the profession): 1) a permanent solution to the sustainable growth formula for Medicare, 2) tort reform, 3) continued protection of reimbursable in-office imaging.  (For background on the ACC and medical imaging, see here.)

For more of our ACC.11 coverage of late-breaking clinical trials, interviews with the authors of the most important research, and blogs from our fellows on the most interesting presentations at the meeting, check out our Coverage Roundup.

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