Elsewhere in this issue of Circulation, Feldman et al1 describe how a classic academic division of cardiology is being transformed into a regional system of cardiac care, research, and education. This proposal is important and timely. Cardiology, like all components of American medicine, is in a dizzyingly rapid transition, driven largely by efforts to restrain the rising costs of medical care.
This pressure to control costs, combined with excess inpatient facilities and specialists (including cardiologists), will lead to ever fiercer competition among care providers. At the same time, if current research efforts continue, enormous further improvements in cardiac care might occur. For example, the development of safe and even more potent cholesterol-lowering and antiplatelet agents could greatly reduce the incidence of clinical coronary artery disease. Although sophisticated methods, including genetic analysis, may be necessary to identify patients at risk for developing atherosclerosis in whom these preventive measures are most appropriate, preventive cardiology is likely to be practiced largely by primary care physicians. This will further reduce the need for cardiovascular specialists.
If research continues to flourish, cardiology is likely to remain an important specialty. Highly sophisticated technical procedures, such as catheter-based gene therapy and cardiac xenotransplantation, that will offer substantial clinical benefits are likely to flow from the research laboratory. An increasingly sophisticated public will insist on obtaining these benefits, even if they are costly. Outcome research and cost-effectiveness analyses will be essential to help resolve the conflict between, on the one hand, the pressures to restrain costs, and on the other, the public demands for the best possible care.
Without strong academic divisions of cardiology, both basic research and the development of techniques to measure the effectiveness, costs, and outcomes of newly developed preventive and therapeutic measures will be arrested. Whether academic cardiovascular programs will remain viable to provide the critical leadership for further improvement of cardiac care is far from certain, because these programs and the institutions in which they are embedded have never been more threatened by market forces.
In the light of these uncertainties for academic cardiology, Feldman's proposal is particularly attractive. It is designed to break down two traditional barriers: first, that between the academic division and its teaching hospital, and second, that between the academic division and the cardiologists practicing in the community. The power of the plan, which appears to be well on its way to execution, lies in the realignment of the incentives of these three entities, which previously operated under an uneasy truce at best and in outright adversarial modes at worst. The need to overcome a third barrier, ie, that between cardiologists and other cardiovascular specialists, including cardiovascular surgeons, anesthesiologists, radiologists, and pathologists, should be incorporated into the plan as well. Also, it must be recognized that cardiovascular care, important as it may be, is only one aspect of health care. Cardiac care cannot be wholly separated from the remainder of the system; however, innovative organizational models in cardiology, such as Feldman's, can be replicated in other areas after their success is proven.
Ideally, the system described in Feldman's article should allow an academic division to improve the cardiac care in an entire region. It should be able to provide the most up-to-date preventive, diagnostic, and therapeutic modalities; accelerate the transfer of discoveries from “bench to bedside”; and provide both patients and practitioners with the opportunity to participate in modern clinical trials. Control of the quality of cardiac care should also be greatly facilitated. Under the auspices of an expanded academic division, the training of both future cardiovascular investigators and clinical cardiologists could be rationalized, with careful consideration of the projected national and regional needs for each group. The opportunity should exist for the development of innovative programs for clinical training not only for cardiologists but also for the primary care physicians and nonphysician healthcare professionals who are likely to play a progressively more important role in the delivery of cardiac care.
Although there is considerable controversy regarding the optimal organization of the academic medical center of the future, there is general agreement that there will be a need for great structural flexibility. The reorganization of academic cardiology described by Feldman et al is a good example of inventiveness and ingenuity. These qualities have always been core strengths of the academic medical center and are likely to be its salvation.
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
- Copyright © 1997 by American Heart Association