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- Kim Allan Williams Sr., MD, FACC, ACC President∗ ()
- ↵∗Address correspondence to:
Dr. Kim Allan Williams, Sr., American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
Professionalism is at the crux of the American College of Cardiology’s (ACC’s) mission to transform cardiovascular care and improve heart health. As the professional home for the entire cardiovascular care team, it is our job to ensure that all members have the tools and resources necessary to provide patients with care that meets the highest standards of accountability, ethics, reliability, and competence.
Last year, the ACC formally adopted the Charter on Medical Professionalism, which stresses the need to place the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health (1). The contract recognizes the increasing importance of these tenets to the physician community during this time of rapid and massive change to the health care system.
The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015—which permanently repeals the Sustainable Growth Rate, establishes a framework for rewarding clinicians for value over volume, and streamlines quality reporting programs into 1 system—ensures that new health care delivery and payment systems are on the imminent horizon. Meanwhile, new parameters for relationships with industry and calls for new levels of accountability are changing how we look at medical education and research funding. Most recently, new requirements for maintaining certification have sparked much-needed debate over self-regulation of the profession of medicine.
The effects of these changes on the physician’s ability to maintain competence and professionalism, as well as the ways to address the “good” and “bad” aspects of these effects, are still up for debate. In fact, the Journal of the American Medical Association (JAMA) committed an entire issue to the subject this past May (2). Leaders from the health care community, government, and academia provided thoughtful perspectives on timely and important issues like reforming the continuing medical education (CME) system, the role of self-regulation, the function of maintenance of certification (MOC), state medical licensing, and the future of undergraduate and graduate medical education funding—all through the lens of professionalism.
Although the viewpoints presented in JAMA varied in terms of the specific details on how best to maintain professionalism, there was a clear sense among nearly all of the commentaries of the need to move beyond the status quo and for greater collaboration among physicians, patients, regulators, and other stakeholders than ever before. “Neither patients nor physicians are well-served on a battleground between professional self-regulation and external accountability,” said Donald Berwick, MD, MPP, president emeritus and senior fellow of the Institute for Healthcare Improvement and former administrator for the Centers for Medicare and Medicaid Service. “From a struggle for local control, health care needs to emerge into an era of wholeness—shared and respectful stewardship. So does the system that prepares physicians for that future” (3).
The ACC agrees with many of the voices included in JAMA that it is time to recalibrate the process in a manner that assists physicians in providing professional, knowledgeable, and compassionate care, while balancing the need to demonstrate ongoing competence. The good news is that we are already making significant progress in a number of areas, including education and quality improvement.
The College’s educational curriculum is driven by evidence-based learning needs. Understanding gaps in learning knowledge, performance, and competence is the first step in the process to design meaningful, effective continuing medical education. In addition, the ACC has embraced a broad array of learning formats that move way beyond the traditional didactic lecture, including interactive clinical cases, skills-based practice, simulated patient provider encounters, and peer-to-peer learning. In the recent health policy statement on the role of advanced practice providers in cardiovascular team-based care, the College also urges expansion of interprofessional education to encourage creative interaction by all members of the team; advocacy around sensible payment reforms; and exploration of emerging technologies to extend the capabilities of the cardiovascular team, including telemedicine and virtual teams to help bring care to underserved regions (4).
Earning public trust is another important component that falls under the umbrella of professionalism—and an area where the ACC is also committed to playing a role. Noam Levey of the Los Angeles Times/Tribune Washington bureau in Washington, DC, cautioned in JAMA that more patient engagement is needed to help fortify public trust in medical professionals. “Patients across the country are experiencing new models of care that are more coordinated, more transparent, more responsive and more personal…. If physicians are viewed as standing in the way of these models, they risk the trust the profession has worked so hard to earn,” he said (5).
As I mentioned in a Leadership Page earlier this year, the ACC is engaged in a number of efforts to build public trust “whether it is showing that we can and will hold each other accountable for providing appropriate, evidence-based care; involving our patients in their care decisions so that they best understand the best course of treatment and why; or using data from registries like those in the NCDR (National Cardiovascular Data Registry) to improve patient outcomes and close gaps in care” (6). ACC’s suite of NCDR registries and its many quality initiatives aimed at helping to close identified gaps in guideline-based care are already helping track and measure performance and patient outcomes. A study published in the American Journal of Cardiology in March 2015 found an association between mandated public reporting and lower mortality rates across the spectrum of indications for percutaneous coronary intervention, including patients who underwent percutaneous coronary interventions for elective indications, acute coronary syndrome, or cardiogenic shock (7). ACC programs, like Hospital to Home and Surviving MI, are finding success at changing hospital culture to improve patient outcomes and increase adherence to guideline-recommended care. The College is also increasingly using its outpatient PINNACLE registry to track adherence to, and effects of, new clinical recommendations relating to blood cholesterol, hypertension, and the use of new oral anticoagulants.
The College is listening closely to its members regarding continuing medical education and MOC and is diligently working to improve the current systems, while also carefully examining alternative options for its members. A recent survey of ACC members on behalf of the Board of Governors (distributed by U.S. ACC chapters to chapter members from April 9, 2015, to May 4, 2015; a total of 3,380 completed surveys were submitted by ACC members) found that the majority of cardiologists remain opposed to the new MOC requirements. Survey respondents also indicated a strong desire to have ACC assume certification and remove MOC as a requirement. Look for more details on the survey in an upcoming leadership page from Board of Governors Chair Robert Shor, MD, FACC. It is important to note that the results are being used to guide ongoing discussions with the American Board of Internal Medicine, as well as to inform the separate ACC task force effort focused on alternatives to the American Board of Internal Medicine. There are some clear hurdles that have to be overcome when exploring alternatives, including costs to members, implementation costs, complexity of structure, and conflicts of interest. Because of these complexities and the need to ensure any that alternative can stand the test of time, this undertaking requires a commitment to thoroughness. The College is moving as quickly as possible in this regard.
Writing in JAMA, Robert Huckman, PhD, and Ananth Raman, PhD, MBA, of Harvard Business School in Massachusetts caution that physicians and other health care professionals need to substantially improve quality and innovation in the near-term or run the risk of “outside forces, such as regulators and policymakers, [becoming] more involved in certification and mandating approaches to improvement” (8). Although there is a clear need for more discussion, reflection, and even policy development around the best approaches for meeting needs of patients, physicians, payers, and the government when it comes to medical professionalism, the ACC remains committed to leading the way in defining professionalism in cardiovascular care, developing and validating educational tools and resources, and disseminating best practices in cardiovascular care delivery.
The ACC exists today to help its members honor their professional commitment to give back to the communities where they live and work—from training to retirement. The College and its leadership are here for you on each step of this journey. Use us.
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