Cardiology as a medical discipline has reached a critical stretch of white water unlike any it has navigated over the past 40 years. The changes our specialty now faces have been brought about not, as in the past, by conceptual or technical advances but rather by cost barriers that will govern every aspect of our work, including education, research, and clinical practice, for as long as anyone can predict.
History: How Did We Get Here From There?
A little more than 40 years ago, when I first entered Dr. Lewis Dexter's laboratory as a cardiology fellow at Harvard Medical School and the Peter Bent Brigham Hospital, cardiac catheterization had been in use for only about 3 or 4 years. It dominated our work in unraveling the questions of circulatory physiology and biochemistry. Shortly thereafter, we began to focus on how the heart functions both as a muscle and as a pump. That was an era of both technological innovation and conceptual advancement best exemplified by new, accurate radiographic imaging techniques. These methods augmented and complemented the physiological pressure-flow measurements and revolutionized the field. They showed us the cardiac chambers and the coronary and other arteries in ways never before possible, thus refining the concept and role of cardiovascular dimension and volume in heart function. All of this culminated in the 1980s with the advent of focused intervention and remarkably effective surgery. Molecular biology, which now dominates academic cardiology, was beginning to find its place in the field. We now have unique drugs for clinical care, and large clinical trials have become commonplace (Fig 1⇓).
But around 1990, the word “cost” crept in. Things began to change as we moved into healthcare reform, which is changing medicine from a profession to a business. This swift and drastic environmental shift has already begun to produce its victims, its victors, and its refugees. The victims will be and are patients, research, community service, and charity care. The victors are the managed care organizations and insurers. In this early sweep, there has already been an unbelievable change in status for both patients and physicians. The challenge to us is to sustain our mission as a profession in the face of sometimes hostile changes in the healthcare environment.
The Advent of Managed Care
Most of us are now dealing with managed care but not necessarily liking it. Some version of managed care has penetrated every corner of the United States. This has led to a perverse transformation of the health system1 in which cash-rich, profit-driven, corporate giants with monopolistic tendencies are circumscribing the medical profession. They view medical care as a cost rather than as the purpose of the business—the so-called medical loss ratio.2 It is an irony, given all the progress we have made, that rendering medical care should be counted as a loss.
Obsession with cost or price has had the desired effect of raising national consciousness and restraining the upward spiral. But this too has had its “price.” For example, pressures to reduce hospital costs have become so great that it is difficult for institutions to support research, education, charity service, or community care—the ordinary correlatives of our everyday work. This poses enormous ethical conflicts for physicians and other professionals. Our ethical responsibility to patients is contested by the economic pressures imposed by the business entity. Hospitals and physicians are squeezed between the patient who needs rational, high-quality care and the for-profit company demanding tight cost control and therefore limiting patient access to care (Fig 2⇓). Crudely put, survival of physicians as professionals is at stake.
Furthermore, such severe price competition has made plan membership unstable. Now the payer, usually the employer, can change health plans at will as more price-attractive packages are marketed. This situation leads to an ever-shifting set of physicians, hospitals, and ancillary services whose primary relationship is with the health plan rather than with the patient. This disconnects the patient and doctor, resulting in a loss of continuity. This perverse effect is just one of many in the new medical environment that run counter to the original philosophy of the health management organization, which was to foster prevention of illness through long-term patient-physician relationships and continuity of care.
Expansion of Primary Care
The pressures to reduce the use of cardiologists are enormous but also apply to all other subspecialists. This trend has eventuated because the primary physician is expected to venture further into the subspecialty disciplines. This overly ambitious goal requires primary physicians to keep abreast of 15 or 20 different clinical areas. Reviewing the career of James B. Herrick, for whom this lecture is named, we find that although he was known as a cardiologist, he wrote papers on hemophilia, sickle cell anemia, and anemia as a cause of angina, as well as his classic paper on coronary thrombosis.3 At the turn of the century and shortly thereafter, it was still possible to make contributions in more than one field. We all know that can no longer be done.
The primary physician does more today than in the past, even without the pressure of managed care, but expecting the primary physician to master the subtleties of divergent disciplines is unrealistic and even irresponsible. There are too many areas to cover, and there are too many areas even within each specialty for one physician to cover everything competently. Erosion of quality and the incursion of errors are inevitable.
In the gatekeeper model of managed care medicine, the primary physician requests fewer tests and recommends fewer procedures. This practice leads to a reduced number of interventions and consultations. Nobody knows what the optimum number of procedures or consultations ought to be, but in a capitated system, the fewer procedures and consultations there are, the better it is financially for the organization and the primary physician.
In one group practice's proposed guidelines for cardiological care, the primary physician would evaluate chest pain, heart murmurs, and palpitations.4 Although the evaluation of chest pain is well within the competence of the primary physician, some murmurs can challenge even an experienced cardiologist. Appropriately, this practice expects its members to differentiate significant heart disease from minimal conditions. But physicians also are expected to interpret ECGs and echocardiograms. Again, these tasks may often lie beyond the proficiency of a primary physician. The practice guidelines go further to include evaluating and treating coronary risk factors, managing hypertension, and treating congestive heart failure and stable angina. These are reasonable expectations for a primary physician, provided that a cardiologist is consulted when needed and that the primary physician recognizes that a need exists. This same group expects the primary care physician to treat “non–life-threatening arrhythmias” and syncope, yet even experienced cardiologists often find it difficult to tell when an arrhythmia is not life threatening. Similarly, determining the cause of syncope is one of the most challenging diagnoses, and yet it is up to the primary care physician in this group practice to decide whether syncope is of cardiac, vascular, or other origin. Finally, their members are expected to manage the in-patient course of the patient who has had an acute myocardial infarction (MI). One questions whether the primary physician would even be available to the hospitalized patient, considering the burden of office duties in the managed care setting. Are we ready to accept the British model of distinct office-based and hospital-based physicians?
Quality of Care
Ayanian et al5 queried cardiologists, internists, and family practitioners on the use of aspirin, β-blockers, thrombolysis, lidocaine, and diltiazem in acute MI (Table 1⇓). Family practitioners would recommend the proven beneficial agents at a much lower rate than either internists or cardiologists. β-Blockers in acute MI would be recommended the least by family practitioners, then by the internists, and finally the most by cardiologists. Conversely, lidocaine and diltiazem, which are of little or no benefit, would be recommended much more by family practitioners than by either internists or cardiologists.
It is important to know how we acquire these types of comparative data. For example, in a recent study comparing internists' and cardiologists' care for patients with unstable angina, the outcome was mixed. Cardiologists had costlier (by $2000) but shorter (by 0.3 day) admissions with about the same clinical outcome while using different evaluation procedures. But one must be cautious not to compare apples and oranges. The authors point out that the populations were actually quite different, with more known coronary disease treated by cardiologists and more patients with new or unknown disease treated by internists.6
The cardiologist needs an assertive approach to the problem of the usurpation of the specialist's realm. By bringing a broader understanding of disease and its management into the arena, we can be the vanguard of new knowledge not readily available to the primary physician. We can build partnerships with primary physicians rather than passively accepting the gatekeeper concept.
Through our broader and more specialized knowledge of cardiovascular disease, we can streamline and delineate the continuum of care. We will be most effective if we focus on those things we know well. We are in the best position to determine the role of primary prevention, to delineate rational practices for established disease, and to formulate algorithms of care.
The cardiologist probably should interact with the primary physician differently than is generally proposed in the managed care setting. He or she should see the potential cardiac patient early, such as during or after the first visit, rather than late in the process. Cardiologists are most valuable when providing consultations when symptoms first present rather than later when things begin to happen that could have been prevented. Cardiologists, similarly, should formally overread ECGs, chest x-rays, and echocardiograms initially reviewed by primary physicians to mitigate error. Substituting an integrated team approach for the gatekeeper model would improve patient care by sharing the responsibility.
By forming partnerships with primary physicians, we can teach them while they teach us. Furthermore, we must involve them in clinical and outcomes research as a means of building an integrated team.
One has to be at the forefront of new knowledge and applications and to be proactive about it. A simple example would be primary physician education about newly recognized coronary risk factors, eg, ACE gene insertion-deletion polymorphism and homocysteinemia. The average primary physician may not be aware of such factors until they are heavily touted in the press. Furthermore, it is questionable whether primary physicians would or should even be looking for such abnormalities because the therapeutic end is not always obvious, and the new knowledge needs to be appropriately focused.
Restrictions on Procedures
The third point we need to address is the reduction in the number of procedures performed by cardiologists in a capitated system. This is partly caused by the loss under capitation of financial incentive to do many interventions. Furthermore, external controls and guidelines are being imposed or promulgated to determine best which patients will benefit from invasive procedures. It is not always possible to demonstrate, for example, that aggressive interventions save lives, reduce morbid events, deliver patient satisfaction, or reduce short- or long-term costs. A simple view of this was given in a comparative data set from the Survival and Ventricular Enlargement study,7 showing that coronary arteriography and revascularization procedures were performed half as frequently in Canada as in the United States (Table 2⇓). Yet in this controlled, randomized clinical trial, all-cause mortality and myocardial reinfarction were exactly the same in the two countries. Disabling angina, however, was somewhat more common in Canada than in the United States. If these results are borne out over and over again in the future, fewer invasive procedures will be recommended and performed.
This will mean that to maintain the volume necessary for high-quality results and the potential for education and research, we will need to establish centers of excellence. In an environment that restricts the recommendation of invasive procedures, the catchment area and the “market share” for any given laboratory or surgical department must increase to generate the volume of procedures required for maintaining quality. Practitioners at all levels will undoubtedly work together in ways we have not thought of before.
Division of Labor and the Roles of the Cardiologist
Fig 3⇓ shows the potential roles of the cardiologist in the managed care setting. Because of the decline in specialist positions, some cardiologists will be required to find other work. The cardiologist who is part of a multispecialty group will probably survive in partnership with the primary care physician. Some cardiologists will manage by practicing primary care medicine part of the time, both for their own patients and for others. Fewer interventional cardiologists will be required than we anticipated when setting up our current training programs. Finally, the single-specialty group should still have a place in certain areas, contracting services, but we do not yet know their long-term feasibility.
Examples of the teamwork that can take place between the primary physician and the cardiologist are shown in Table 3⇓, which presents an integrated team approach to secondary prevention of cardiac risk factors.8 A primary care physician, cardiologist, and nurse or equivalent divide the tasks according to the skills of each. For example, if a patient wanted to quit smoking cigarettes, the primary care physician would make the recommendations, but the nurse would work with the patient in repeated short visits. Screening for and management of lipid disorders would be done by the primary physician, but the treatment plan would be established with the early input of the cardiologist because control of lipid levels has become ever more complex and extends beyond routine recommendations of diet and the statins. A partnership and team approach helps in delivering appropriate therapy and with long-term patient compliance.
For each risk factor, one can rationally define a role for the primary physician, the cardiologist, and the physician extender. By such a division of labor within a group practice, the goal of secondary prevention can be realistically met.
What does this mean for the cardiologist? First, we have to redefine our task. Within every group, someone must be willing to develop a plan for adapting to managed care. It is important that one person accept this task as his or her responsibility. Yet managed care should not be a preoccupation of the entire group. Not everybody on the team needs to be involved with such planning, although all should cooperate. If we can achieve an appropriate division of labor, we will still be able to achieve the traditional goals that have made American cardiology great.
Fellowship Training and Cardiac Research
Finally, cardiology training programs must accommodate a medical environment that is likely to be somewhat erratic for many years. Fellowships should prepare graduates for practicing in a variety of circumstances. We need to return to a strong, basic clinical program stressing 2 to 3 years of solid clinical knowledge and hands-on skills, eg, how to use a stethoscope and read ECGs. Then there needs to be a reduction in the number of cardiologists who take advanced training in invasive and interventional areas so that we do not have too many overqualified and underemployed cardiac subspecialists. Finally, the curriculum must address healthcare economics and teach how to practice in a real-world managed care setting.
The managed care environment is not at this point generous with funds for basic research, but mere outcome-based health services research cannot be allowed to supplant sound bench science, or the very future of medicine will be jeopardized. Even the profit-driven health maintenance organizations cannot be blind to the fact that their prosperity cannot be maintained forever without enriching the fund of knowledge that makes such prosperity possible.
In summary, the current economic barriers to the continued growth of cardiology as a specialty discipline will test our professional character and our creativity in ways unforeseen 20 years ago. Perhaps our greatest challenge will be to keep our heads above the swirling waters of profit-driven medicine and to maintain control of our own self-defined standards so that the stature and progress of our profession do not founder on the dictates of commercial enterprise.
Delivered as the James B. Herrick Lecture at the American Heart Association Meeting, Anaheim, Calif, November 14, 1995.
- Copyright © 1996 by American Heart Association
Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA. 1912;59:2015-2020.
Clinical guidelines ‘road-mapping’ primary care entry into specialty practice. In: Cardiac Capitation: Vision of the Future for Specialty Care. Washington, DC: The Advisory Board Co; 1995:98.
Rouleau JL, Moye´ LA, Pfeffer MA, Arnold JMO, Bernstein V, Cuddy TE, Dagenais GR, Geltman EM, Goldman S, Gordon D, Hamm P, Klein M, Lamas GA, McCans J, McEwan P, Menapace FJ, Parker JO, Sestier F, Sussex B, Braunwald E, for the SAVE Investigators. A comparison of management patterns after acute myocardial infarction in Canada and the United States. N Engl J Med. 1993;328:779-784.
Preventing heart attack and death in patients with coronary disease. Smith SC Jr, Blair SN, Criqui MH, Fletcher GF, Fuster V, Gersh BJ, Gotto AM, Gould KL, Greenland P, Grundy SM, Hill MN, Hlatky MA, Houston-Miller N, Krauss RM, LaRosa J, Ockene IS, Oparil S, Pearson TA, Rapaport E, Starke RD, for the Secondary Prevention Panel. Circulation. 1995;92:2-4. Consensus Panel Statement.