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- Richard A. Chazal, MD, FACC, Immediate-Past President, American College of Cardiology∗ ()
- ↵∗Address for correspondence:
Dr. Richard A. Chazal, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
We in the cardiovascular profession can learn a lot about managing change from this year’s American College of Cardiology (ACC) Annual Scientific Session host city—Washington, DC. The mantra that “change is inevitable” could be the city’s motto. Each election cycle brings change, often dramatic. As new individuals take office, others leave, shifting the balance of power and potentially the course and direction of our nation.
The rate of change everywhere also means one might best avoid becoming too comfortable with the status quo. Those who embrace and accept that change is occurring are best positioned to succeed. They are able to identify and seize new opportunities, while also knowing when to exercise patience and/or take a different approach to solving a problem.
The practice of medicine has seen its fair share of change since the first evidence of surgery around 5,000 BCE (1). For millennia, physicians and healers practiced intuitive medicine that relied on observation, anecdote, and experience to treat specific symptoms. Around the mid-20th century, rapid growth in technology and the ability to capture and quantify data began to transform the practice of medicine into what is now referred to as “evidence-based medicine.” This evidence-based care has also allowed practitioners to go beyond treating symptoms and illness to increasingly focus on preventing diseases. Having relatively recently evolved from anecdotal to evidence-based medicine, we are already on the cusp of the next evolution toward personalized medicine!
As we look to the future, significant changes are on the horizon. Seventeen years ago, a team comprised of health care futurist Joe Flower, along with past and future ACC leaders Leonard Dreifus, MD, MACC, Alfred Bove, MD, MACC, and Bill Weintraub, MD, MACC, published a paper in JACC that predicted “the combination of demographic shifts and cost pressures and a flood of new technologies—both biological and digital—promise that the new century and the coming generation will see the creative destruction and rebirth of what we know today as healthcare” (2).
As mentioned in a previous Leadership Page, their predictions presaged much of what is now happening (3). Personalized, algorithm-based precision medicine is increasingly available and will undoubtedly have significant effects on the way care is delivered going forward. Rapid advances in diagnostics and therapeutics are promising breakthrough treatments in heart failure, managing hyperlipidemia and hypertension, and saving and improving the lives of patients who were previously considered untreatable. Inroads are being made with biomarkers, nanotechnology, gene and stem cell therapies, 3-dimensional printing, and other technologies and treatments.
In addition to the changes in technological approaches to medicine, there is evolution in care delivery, both in the United States and globally. Over the last several years, health care reform efforts in the United States have forced practices and cardiovascular professionals to rethink the ways that care is delivered. Economic pressures related to health care costs and concerns about quality and overall patient outcomes have resulted in the passage of laws like the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.
MACRA, through the creation of the Quality Payment Program and repeal of the flawed Sustainable Growth Rate formula used to calculate Medicare physician payment, establishes a definitive framework for moving Medicare from a volume- to value-based system. Because of the economic underpinnings of the move to a value-based system, repeal or fundamental change is not a political likelihood, even with a new presidential administration and Congress. At the ACC’s Cardiovascular Summit in February, physician leaders continued to stress the need to prepare for MACRA now (4). The law is likely to bring some of the most dramatic systematic changes we could see in our professional lifetime.
How all of us learn and how we keep up with education requirements is another area of immense change. In addition to increasing online learning opportunities, mobile applications for use at the point of care continue to be developed. Mobile applications provide not only a care tool, but a new way of learning as well. Live educational programs have evolved to support interactive and virtual learning. Although larger meetings remain engaging and valuable, smaller and more focused meetings are gaining in popularity. Successful educational organizations, the ACC included, increasingly recognize the importance of having lifelong learning offerings that are developed in response to learner needs (“needs-based learning”) while leveraging available technology.
Evolving—and often confusing—continuing education processes also pose significant challenges for cardiovascular professionals, particularly in the United States. One of the ACC’s strategic priorities is to assist our members in maintaining documentable professional competence. As part of this effort, the College has spent the last several years advocating for solutions to the American Board of Internal Medicine’s Maintenance of Certification process. Although there is still work to be done, there has been significant progress in these efforts. Most recently, the ACC has been involved in working toward developing a society pathway alternative to the 10-year Maintenance of Certification examination that, for cardiology, might be modeled after the College’s popular self-assessment products, such as the ACCSAP (Adult Clinical Cardiology Self-Assessment Program) 9.
Shifting patient demographics also bring new challenges and opportunities. The number of patients over the age of 65 years who are living longer with cardiovascular diseases continues to grow exponentially (5). In addition, increasing numbers of individuals of all ages are presenting with preclinical cardiovascular disease, based on risk factors such as obesity, diabetes, hypertension, and hyperlipidemia. Cancer survivors with cardiovascular disease related to malignancy or treatment present new challenges. Continuing issues related to health care disparities persist, demanding our response.
On the professional front, although we have grown more diverse in terms of sex, race, and ethnicity, there is yet a need to address issues of pay equity, work/life balance, and further diversification of our ranks to meet the needs of our patients. A 2015 study by former ACC President Pam Douglas, MD, MACC, incoming ACC President Mary Norine Walsh, MD, FACC, and others showed not only substantial salary differences between male and female practicing cardiologists, but also dramatically different job descriptions—despite sharing the same specialty (6). More recently, data from the ACC’s third Professional Life Survey conducted by the Women in Cardiology Section suggest an opportunity for cardiovascular leaders (men and women) to focus on ensuring that future cardiologists represent the best and most inclusive group possible, free of discrimination (7).
Just as in the general population, practicing cardiologists are also aging, portending potential shortages in those who would follow in our footsteps. The good news is that the care team is growing to span much of the continuum of care—a needed evolvement to meet the needs of those with cardiovascular diseases. Nurses, nurse practitioners, physician assistants, cardiovascular administrators, pharmacists, emergency medical personnel, and more are playing increasingly larger and more critical roles in the care and treatment of patients. Recognition of their unique skill sets and how they can best integrate into the overall care team is essential.
All of these environmental changes are having effects on the College itself. The ACC is now home to more than 52,000 cardiovascular professionals around the world. Our international members and our cardiovascular team members are 2 of the fastest-growing member segments. In addition, a growing number of hospitals and institutions around the world are taking advantage of the College’s clinical data registries, quality improvement campaigns, and more recently, accreditation services to identify gaps in care, improve adherence to clinical guidelines, and participate in federal quality improvement programs.
How do we address all of this change without feeling overwhelmed and frustrated?
First, all of us must take a page out of the Washington, DC, playbook and accept that change is occurring regardless of what we may wish. We must prepare how best to respond, while also knowing when response is necessary and likely to be effective. With each new announcement of law or policy change, we must, both individually and as a community, thoughtfully analyze and decide how best to move forward.
Over the last year, the ACC has been working to implement the first phase of the new governance structure that enables the College to be more strategic, nimble, and accountable in meeting such challenges, and determining when to respond—and when to observe. The College’s mission statement, operationalized by the 5-year strategic plan, serves as a roadmap through all of the change. It is the lens through which we assess new ideas and reassess old ones, making certain we remain on track to best help members succeed and thrive in the new health care environment so that we can best serve our patients.
Educating ourselves and our patients about the changes ahead and what it means both personally and professionally is another important step in the needed process. Nelson Mandela said: “Education is the most powerful weapon which you can use to change the world” (8). It is our responsibility to educate ourselves to deal with change and also to help aid our patients in an evolving environment.
We must continue to find ways to best leverage new technologies. We must help develop and use new diagnostic and therapeutic drugs and devices in a responsible, cost-effective, evidence-based manner. We must embrace colleagues with varying backgrounds and viewpoints and learn from one another. We must engage in respectful discourse that focuses not just on problems and challenges, but also on workable solutions.
Implementing change is difficult and the transition is fraught with anxiety. Epictetus said, “It's not what happens to you, but how you react to it that matters” (9). We can decide whether to emphasize the inherent challenges or the inherent opportunities presented to us. We must meet change head-on and not squander opportunities to transform cardiovascular care and improve heart health. Cardiology has long been at the forefront of change and innovation—let us ensure that this legacy continues.
- 2017 American College of Cardiology Foundation
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- ↵David KB. MIPS tips for cardiologists feeling clueless about MACRA. Cardiovascular Business. January 30, 2017. Available at: http://www.cardiovascularbusiness.com/topics/healthcare-economics/mips-tips-cardiologists-feeling-clueless-about-macra. Accessed February 13, 2017.
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