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Carl J. Pepine, MD, MACC, Professor and Chief, Division of Cardiovascular Medicine, University of Florida College of Medicine, Box 100277, 1600 Archer Road, Gainesville, Florida 32610-0277, USA.
Over the last several decades, we've seen more and more cardiovascular (CV) subspecialty societies develop, opening their memberships to highly trained populations of practitioners, academics, and researchers as well as specialized nurses, technicians, and other nonphysicians dedicated to CV care. These specialized societies range from the Society for Cardiovascular Angiography and Interventions (SCAI) (of which I am a member) to societies dedicated to newer, emerging technologies, such as the Society for Cardiovascular Magnetic Resonance Imaging (SCMRI). Subspecialty societies can serve either large CV communities, as does the American Society of Echocardiography (ASE) with more than 8,000 members, or relatively small groups, sometimes with only 1,000 people or less (Table 1).
So far, the segmentation of CV subspecialties seems to have had positive results in patient care and physician education. The CV specialty, generally regarded as the largest trained subpopulation of internal medicine, often finds additional strength in the number of practicing physicians it includes and in the girth of its institutional contributions, both in terms of patient care and revenue generation. It is also widely evident that by providing principal care, the CV specialty has somewhat eclipsed internal medicine. In most hospitals, CV activity dwarfs other practice areas. And today, most CV specialists choose to belong to the American College of Cardiology (ACC) or another CV subspecialty society as their primary medical society, rather than a medical society of generalists.
The advent of the American Board of Internal Medicine (ABIM) certification programs for Added Qualification Boards in electrophysiology and interventional cardiology further proves that CV subspecialties have taken on vital lives of their own, independently credentialing highly specialized physicians with specific professional interests and relatively few peers. I expect that Added Qualification Boards for transplant and heart failure are not too far away in the future. As CV specialists, we can take pride in the fact that the link between longer, more specialized training and quality patient care is secure.
The power of numbers
Despite the trend and need for CV specialists to focus tightly on specific components of care, however, we would do well to maintain a certain security by ensuring that we all continue to communicate and work as a homogenous, unified entity. Radiologists, for example, have managed to keep their subspecialties under one roof: institutionally, in the Department of Radiology, and professionally, in the American College of Radiology. In so doing, radiologists have preserved an important voice, united in speaking for all their professional interests.
Subspecialty divisions of cardiology, by contrast, are often stand-alone units operating within the larger Department of Internal Medicine, sometimes alongside the Cardiology Division instead of within it. Though they are small entities, these subspecialty divisions compete with one another and with much larger practice specialties, such as radiology, for space, patients, facility and equipment funds, and reimbursement dollars.
The potential problem with CV medicine as a segmented specialty is that the challenges of the practice environment become greater while the abilities to: 1) lobby effectively, 2) present robust education programs, and 3) interact effectively with various other medical groups are diminished. Inevitably, diminished numbers in CV subspecialties—through diffusion—lead to diminished influence for the CV specialty as a whole.
Creating a coalition for the greater good
By the time the Cardiovascular Subspecialty Societies Leadership Group met in Washington, DC, in the fall of 2002, the scenario for diminishing influence among subspecialties was impossible to ignore. The ensuing summit provided the jumping-off point for establishing the Coalition of Cardiovascular Organizations (CCO), a coalition designed to promote and encourage collaborative efforts in advocacy and government relations, patient education, continuing medical education programs, and documents that address issues of quality care.
The establishment of the CCO is the first step in bringing the 10 groups with similar health care interests and goals under one umbrella. The coalition groups believe that working together is more advantageous than working independently and that more can be accomplished together than individually. The ACC, one of the coalition groups, represents the professional population of CV practice (i.e., practitioners with terminal degrees, most certified by some higher board of quality). However, as part of the coalition, the College's membership efforts are enhanced and strengthened by the addition of health care societies populated with technicians, nurses, physician assistants, and other health care workers who are generally more closely aligned with patients than we specialized physicians can be. The unique association the CCO provides enables us to address health care issues with a broad base of support and a collective perspective on quality CV care, despite the fact that specific interests of various coalition groups may differ.
Notably, leaders from the 10 coalition groups were able to form a consensus on rotating the leadership for the CCO. They also committed resources to fund the coalition's first year of operation and hired a coalition administrator to advance the preliminary agenda set forth in summit meetings held prior to the coalition's actual establishment. More heartening is the fact that other specialty groups are interested in adding to our productivity and joining the coalition's ranks. Both the American Society of Hypertension (ASH) and the Association of Black Cardiologists (ABC) will act as observers when the original 10 groups further their agenda at the next CCO meeting in November. In the future, we hope that as many of the subspecialty groups as are interested can be involved; by no means is the CCO an exclusive coalition.
Politically, the CCO concept offers a great advantage to ACC members. Clearly, even during a time of unprecedented technological and intellectual advances in CV care, we face numerous and daunting clinical and policy challenges. The CCO, if it works as intended, will strengthen our education programs and quality improvement initiatives and will provide us with a strengthened voice to pursue our advocacy goals of making the practice environment more conducive to both quality patient care and CV practice in general.
↵1 President, American College of Cardiology
- American College of Cardiology Foundation