Author + information
- Francis J Klocke, MD, MACC∗,* (, )
- Pamela S Douglas, MD, FACC†,
- Steven E Nissen, MD, FACC‡ and
- Richard L Popp, MD, MACC§
- ↵*Reprint requests and correspondence: Francis J. Klocke, MD, MACC, Director of Feinberg Cardiovascular Research Institute, Professor of Medicine, Northwestern University Medical School, 303 E. Chicago Ave., Tarry 12-703 (T233), Chicago, Illinois, 60611-3008
The mission of the American College of Cardiology (ACC) has always been and will continue to be the fostering of optimal cardiovascular care and disease prevention. The challenge currently facing the College is how best to continue to accomplish this mission in view of changes in demographics, technology, and health care utilization and costs, as outlined in the previous articles from the 50th anniversary Forum on the Future.
The College has thus far accomplished its mission through four major areas of activity: professional education, advocacy (for both optimal care and, more recently, the value of the cardiovascular professional), clinical guidelines and other standard setting, and promotion of research. Several developments will influence how the College balances these activities during its second 50 years: New technology will allow educational content to be personalized to the needs of individual physicians. In addition to the College’s traditional lecture and didactic programs, education to improve patient care delivery will require new approaches and documentation. Pressures from public- and private-sector payers and policymakers for physicians to document performance in order to improve patient care will continue to increase. Patients will demand more information to manage their diseases, including sophisticated medically oriented information. The Internet will be an important source of information (and disinformation); however, information overload will magnify the need for both physicians and patients to sort out information essential to daily practice and disease management.
All of the tremendous changes that have already taken place in cardiovascular medicine will continue to evolve and demand the College’s attention. The Forum on the Future identified issues related to demographics, technology, and utilization and costs of care. During the next 40 years, the aging of the baby-boom population will raise the prevalence of chronic heart disease and increase appreciably the number of deaths attributable to heart disease. The need for cardiovascular caregivers will increase commensurately. Cardiovascular disease will continue to be situated at the nexus of advanced technologies—informational as well as biological. An unknown portion of potential developments in diagnostic and therapeutic technology will enter the realm of clinical applicability, and advances in genomics will have enormous impact.
Issues of additional importance to the cardiovascular practitioner include the changing role of the clinician, the impact of the information age, the role of the practitioner as practice manager and leader of the health care team, and the changing work force and need to redefine careers.
The changing role of the clinician
The cardiovascular clinician traditionally functions as a consultant, providing a mix of cognitive and technical skills. These roles are evolving, as many clinicians also function as primary care physicians and as numbers of hospitalists and proceduralists grow. To function effectively in the future, the cardiovascular specialist will have to provide patient-centered, not technologically oriented, care. The clinician must have ready access to practice guidelines and be conversant in disease management algorithms. Alternative areas of expertise and involvement, including vascular medicine, community health, alternative medicine, and wellness, may need to be incorporated into current practice. The introduction of products of molecular biology and the genomics revolution into the realm of clinical medicine is fast approaching and is likely to result in dramatic changes in therapeutics and diagnostics. Our current concepts of cardiovascular disease may be profoundly altered.
Other changes will further alter the physician’s job description. Nonphysician colleagues, including nurses, physician assistants, and technologists, have become important partners—no longer simply physician extenders. More practitioners and academic cardiologists are performing clinical research. Indeed, academic-based cardiologists and practice-based cardiologists are now facing the same issues and have more in common than ever before. Finally, continuing medical education (CME) must address these new needs and develop new methods of education that will help physicians stay up to date in procedural specialties and in the acquisition of new skills.
The impact of the information age
The tools of the cardiovascular practitioner have advanced far beyond the stethoscope, and computer fluency is now a near-mandatory skill. Many physicians are already familiar with billing systems, but now both inpatient and outpatient medical records are being computerized. The practitioner needs to know how to use both data- and event-tracking systems to optimize the quality of care and the efficiency of its delivery. Clinical care will require a more ready access to computer databases, online reference materials, and other information technologies.
Computers have made it possible to assess many aspects of cardiovascular business and practice, and physicians are now more often being evaluated, profiled, and credentialed on the basis of computerized fiscal, process-of-care, and outcomes data. Cardiovascular laboratories and practitioners are becoming targets of new credentialing and performance measurement initiatives, many of which rely on computerized databases. Cardiovascular specialists in general and the ACC in particular are likely to be involved in setting these standards. Finally, computers offer unique opportunities to enhance communication, learning, and teaching for both practitioners and patients. Access to patient records for urgent or distant care will be facilitated by the Internet.
The practitioner as practice manager
The business of cardiovascular practice has changed dramatically, and optimal practice now includes business as well as clinical expertise and effectiveness. The cardiovascular practitioner must be knowledgeable about contracting; billing and coding; alliances and mergers; group governance and compensation strategies; human resources issues, such as hiring, firing, and personnel evaluation; quality management; and marketing and finance. Maintaining this knowledge base often requires extensive collaborations with business or other administrative or organizational personnel. These areas, while crucial, are nearly absent in cardiovascular training and continuing education programs and, therefore, are being learned by trial and error.
The practitioner as leader of the health care system: enhancing personal and professional effectiveness
With the dramatic changes in medicine and the increasing rate of change, the effective practitioner will need expertise in time management, decision making, team membership, strategic planning, and leadership skills, including negotiation, conflict resolution, and the ability to effectively conduct meetings. The practitioner needs to interact with a variety of entities, including the community, payers, hospital administrators, and health maintenance organization medical directors, and to manage these relationships effectively. The practitioner should be able to identify personal and practice needs and initiate and sustain change to achieve clearly articulated goals. As the leader of the health-care team, the cardiovascular practitioner is often the primary change agent. The ability to learn continually and teach and lead others in new directions is crucial.
The changing work force and the need to re-define careers
Accompanying the many changes in medical care delivery is an increasing variety of alternative career opportunities for cardiovascular professionals, including the pharmaceutical and biotechnology industries and employment by managed care providers and payers. Even clinicians are much less likely to remain in a single or uniform practice setting throughout their active careers. Job satisfaction is declining, and stress levels are rising. Cardiovascular practitioners are now faced with the need to manage their careers professionally, personally, and organizationally. The thirtieth Bethesda Conference on the future of academic cardiology highlighted changes in careers in that sector. Women and minorities must be made to feel welcome in cardiovascular medicine if the profession is to take full advantage of all available talent. Without personal career satisfaction, our profession cannot perform optimally, and cardiovascular medicine will not be able to continue to attract and retain the trainees best able to serve our patients.
In summary, the shifting financial basis of medical care has not only altered clinical practice but also has substantially increased its complexity. In addition to clinical care, the cardiovascular practitioner, whether in an academic or a community setting, is now required to be a manager and an administrator, to possess skills in information technology, and to deal with both a changing work force and the new needs of patients as health care consumers. Fiscal and business issues occupy an increasing amount of physicians’ attention, and even clinical accountability has shifted from patient to payer. The change in job description and the loss of control, autonomy, status, and revenue associated with managed care have markedly reduced professional satisfaction. These changes have substantially modified what it means to be a cardiovascular practitioner. Practitioners need to hone their skills in managing change, understand and benefit from the flux of relationships, cooperate as well as compete, learn to use intuition in conjunction with objective analysis, reassess their roles in the health care system, and understand the value of a systems approach to cardiovascular medicine.
While physicians become more beholden to payers, patients also are changing. The U.S. population is growing older, and minorities are becoming pluralities. Patients have become health care consumers—playing active roles in their own diagnoses and treatments; demanding quality care, service, information, and value; and seeking information through health libraries and the Internet. Both payers and patients are seeking more objective measures of quality and are becoming aware of and acting on real or perceived differences in care delivery. Alternative, or complementary, medicine is a growing market sector that even the most traditional clinician can no longer ignore. Practitioners must be able to assess their markets and the future changes in them and tailor business and practice to address present and future trends.
Equally important, the patterns of cardiovascular disease are changing, with decreasing coronary artery disease mortality, increasing heart failure prevalence, increasing recognition of the importance and feasibility of prevention, and vascular disease being more closely incorporated into the cardiovascular specialist’s domain.
The evolving ACC response
The College must continue to meet the needs of cardiovascular practitioners and their patients (i.e., the health care “consumers”) by developing programs, activities, and strategies that will help them respond to their changing roles. If the ACC is to remain the primary professional organization for the cardiovascular practitioner, then it will need to re-examine and retool itself continuously. This process will assist the College to better understand and help define the optimal role of the cardiovascular specialist. These efforts will lead to innovation in continuing education and be influential in the writing of practice guidelines, placing greater emphasis on supporting the practitioner’s ability to provide quality patient care. In short, they will allow the ACC to identify and develop appropriate and effective mechanisms to adapt to the changing health care environment.
A few recently undertaken activities are illustrative. Specific directions that will add value to the ACC for its member physicians and their patients have been articulated by the College’s Task Force for the Twenty-first Century:
1. Restructuring current educational activities and using new technologies to improve patient care more directly,
2. Increasing public- and private-sector advocacy to ensure that adequate resources are available to guarantee optimal patient care in the most appropriate health care environment,
3. Developing strategies to implement clinical guidelines and standards to attain optimal patient care, and
4. Developing and applying measures to evaluate the effectiveness of these new directions.
These steps will require new approaches for setting priorities, making decisions, and allocating finite resources while maintaining consensus. Changing technology will play a pivotal role, driving efforts in education, guideline development, and advocacy; and the ACC will continue to play an important role in evaluating new technology and determining its proper use.
The Task Force on Strategic Directions for CME at the ACC is actively re-examining how the College can best respond through its traditional primary mission of education. In the future, the ACC will provide CME based on a new, individualized model linked to clinical practice. This model will include methods of assisting members in defining their own CME needs and identify ways in which the education of patients, and perhaps the ancillary health care providers assisting our members, might be linked to physician education. “Just-in-time” CME and the electronic delivery of CME will be top priorities in providing education. In addition, educational activities will focus more on the development, promulgation, and widespread clinical application of guidelines as well as the assessment of the effects of these guidelines on clinical outcomes. This effort will involve new investments in designing and delivering professional education while redirecting current investments in selected activities. Tighter links between educational efforts and guideline development also are being forged to create a seamless continuum of knowledge and its practical application.
The ACC-National Cardiovascular Data Registry™ has been initiated to collect data to measure and improve patient care. Mechanisms for providing members with information that is useful in their own practices will be emphasized. Data relative to diversity of care (e.g., among regions, genders, and minorities) are expected to be helpful in promoting quality and consistency of cardiovascular health care. The College will feel compelled to develop its own data sources or draw heavily on those compiled by others in an attempt to define best practices. The ACC will then include these in educational materials and guidelines and, if necessary, advocate for them.
As a result of rapid and dramatic changes in health care delivery and reimbursement in the U.S., the ACC has become a more vocal advocate on behalf of our patients and the quality of the health care they receive. The College has launched a number of initiatives in recent years to address issues such as access to specialty care, declining reimbursement as a consequence of Medicare policies, and proper current procedure terminology coding. These efforts continue to require careful matching and allocation of finite resources to ACC responsibilities and member needs. The College will continue to step up its efforts in the advocacy arena within this framework, reflecting the increasing importance of responding promptly to legislative or public policy initiatives at the state and national levels that affect quality cardiovascular care.
The evolution of the ACC from an education-based society in 1949 to today’s organization, focused on member services, education, advocacy, and clinical practice, illustrates why it continues to remain the primary professional organization for cardiovascular specialists. The ACC’s strength lies in its commitment to respond to the changing needs of its members and their patients and in reaching out to other cardiovascular organizations to forge a united front for the future.
- American College of Cardiology