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President’s page: convocation address
George A. Beller, MD, FACC1
Reprint requests and correspondence: George A. Beller, MD, FACC, Cardiovascular Division, Department of Internal Medicine, Health System, University of Virginia, P.O. Box 800158, Charlottesville, Virginia 22908-0158
I am deeply honored to be installed as the first president of the American College of Cardiology in the twenty-first century. Indeed, it is a great privilege to be serving the specialty of cardiovascular medicine, which has seen so many spectacular advances during the 51 years since the ACC was first founded.
My own decision to become a cardiologist was made in my first year of medical school, following the cardiovascular section of our physiology course. I was awed by the realization that this finely tuned muscular pump—the heart—was exquisitely controlled to provide oxygen and nutrients to all organs of the body by beating on the average of 70 beats a minute for 70 or more years. Now, we imagine that, by 2050, we may even be able to generate replacement hearts for patients with severe disease, using embryonic stem-cell technology.
During the past 50 years, there has been an explosion of new knowledge regarding the biologic mechanisms of cardiovascular disease. This knowledge and the emergence of new technology and new pharmacologic, interventional, and surgical therapies—coupled with lifestyle changes in the American population—have contributed to a remarkable 60% decline in mortality from coronary artery disease and stroke. For example, the death rate for someone hospitalized with an acute myocardial infarction in 1962, when I started medical school, was as high as 40%. Today, it is 4%.
Despite this impressive reduction in mortality, we know that the prevalence of chronic heart disease is going to increase dramatically. Over the next 30 years, the number of patients with chronic heart disease will grow by 66% (1).
This is because of the aging "baby boomer" population. By 2050, the number of Americans 65 years and older will double from nearly 40 million to 80 million (1). These patients will have more complex disease and will need more cardiovascular procedures and operations. The implication of our having a larger, older, and sicker population of patients with heart disease is that we may need to markedly increase—perhaps even double—the number of cardiovascular specialists during the next 50 years. So, we’ll need to train more, not fewer, cardiologists to meet this need. We must attract the best and the brightest children of the "boomers" into our profession.
Along with this expanded workload, there will be increased pressure on us as specialists to demonstrate and measure the quality of the care we deliver. Patient outcomes and individual physician performance will be more important than ever. Outcomes and performance will be closely monitored for the purpose of improving patient care. This is why we have to integrate evidence-based guidelines into our daily practice. Even though many physicians don’t follow the practice guidelines very well, we know that these guidelines do, in fact, improve the quality of our care.
For the same reason, we need to consider the value of any new technology, measuring whether its cost produces an incremental benefit for patients. Doing so will help us eliminate inefficient diagnostic or therapeutic modalities. This is more important than ever. Healthcare expenditures are approximately 1 trillion dollars today, and they’re rising. For heart disease alone, it is expected that costs will increase more than 50% in the next 25 years. If we, as physicians, do our part in practicing evidence-based medicine, we should be able to contain these rising costs without sacrificing quality.
But we will never achieve high quality and contain costs as long as we have 44 million people in this country who are uninsured. This massive lack of insurance impedes the access to prevention and treatment services for a large segment of the population. It delays diagnoses and diminishes health outcomes. Limited access to healthcare is a critical problem in both the impoverished rural and the densely populated urban areas of our country. Death rates from heart disease are highest in these areas, yet they are the places where we have the fewest cardiologists. If these people don’t get to us early, they’ll never reap the benefits of the strides we’ve made in cardiovascular prevention and treatment, and we will not achieve our goal of further reducing the mortality and prevalence of cardiovascular disease.
This is really disturbing. Here we are ... living in a booming economy—an $8 trillion economy—with the lowest unemployment rate in 30 years, and yet we can’t provide affordable, quality healthcare to all of our citizens. I agree with Dr. Nancy Dickey, past president of the American Medical Association, who remarked, "Our nation is too rich and too capable and too compassionate to let more than 43 million people face the daily challenges of their lives without access to healthcare" (2). Universal coverage is one of the six basic principles of Dr. Tim Garson’s proposed new healthcare system for 2010 that he unveiled in his plenary address. The American College of Cardiology is already advocating for universal healthcare coverage for all Americans. As president of the College, I will be going to Capitol Hill this year to make our voice heard.
In addition to our problem with the uninsured, we practice, unfortunately, in an environment in which a greater emphasis often is placed on cost reduction than on quality, and physician autonomy is continuously under attack. This has undermined the physician-patient relationship. Certain managed care organizations still provide incentives for physicians to do less, rather than more. We cannot allow such incentives to exist. We must resist them.
This and other pressures in the current healthcare system, such as decreasing reimbursements, risky contracts, and falling hospital revenues, are bearing down on us. But we must do all we can to preserve our patients’ trust in us and provide them with the quality of care we know they need. We need to change the system so we can spend less time pushing paper and more time healing patients.
So, you’re probably asking yourselves, with all of this increased clinical and bureaucratic work, and the additional pressure of increased scrutiny, how can we keep up with the scientific knowledge that is necessary for providing our patients with the best care? How do we tackle information overload? One answer is the Internet. New online technologies will soon permit us to educate ourselves faster and better. We’ll have instant access to the latest medical information, including new and revised practice guidelines. More than 80% of ACC members already use the Internet to search for medical information. During my presidency, one of my primary goals is to have the College develop innovative ways to help our members receive their continuing medical education by electronic means. We hope to offer enhanced database technologies that are tailored to an individual’s learning needs. We want to make information accessible to you anywhere, anytime. For example, within the year, we expect that you’ll be able to access all the ACC guidelines at the bedside, through your Palm Pilot.
Patients are hungry for medical information. A recent Harris Poll shows that three out of four of Americans who go online do so to access medical information. Our patients will come to us with reams of Internet printouts. We will receive lengthy emails with attachments describing new research that affects their diseases. The positive news is that we will have more informed patients. But they will still need our help evaluating this new information and personalizing it to their situations. We are now exploring ways to establish a patient Internet portal where they can get the most reliable cardiovascular information.
Another technological advance that will make us more efficient in providing care is the electronic medical record. It could eliminate the inefficiencies and mistakes associated with the use of paper-based medical records. It should also markedly decrease medical errors. These types of errors are often contributed to by our illegible handwriting. The Institute of Medicine estimates that medical errors are responsible for the deaths of between 44,000 and 98,000 people a year in the US (3).
New technology will offer opportunities, but it will also present some significant ethical dilemmas. This is especially relevant because, if researchers and clinicians lose their scientific objectivity for potential financial gain, it could endanger patients and the integrity of our specialty.
I want to emphasize, in particular, to the incoming Fellows of the College, three specific situations that may present potential conflicts of interest. First, some of you will become inventors of new devices, or discoverers of innovative treatments, that will be of potential benefit to patients with cardiovascular disease. If you are an investor in your discovery, you could become very wealthy. This can present a significant conflict of interest if you are responsible for conducting and analyzing the results of clinical trials relevant to your discovery and you fail to disclose your personal investment. For this reason, you must remove yourselves from active participation in these trials and remain neutral. You must also disclose any potential conflicts of interest when presenting your research results at meetings or when publishing them.
A second ethical challenge arises with the need to disclose to patients all the risks from potentially dangerous new treatments such as gene therapy using viral vectors. We must let patients know all the risks, and we must explain those risks in language that is easily understood. We should also tell patients about any financial ties we have to companies sponsoring or funding the research.
Third, many of you will be asked to give lectures that are sponsored by industry. This kind of financial support is vital to the enhancement of educational activities in our specialty, but it must be given to us unconditionally. In this area, disclosure is also mandatory. Moreover, your presentations must be objective and unbiased. Generating and disseminating unbiased and objective scientific information is the cornerstone of the educational agenda of the ACC.
As you, new Fellows of the College, immerse yourselves in your future careers, make your voices heard in advocating for your patients and our specialty. When you identify injustices in the healthcare system where the sacrosanct patient-doctor relationship becomes jeopardized, speak out! If access to high-quality, affordable healthcare continues to be unavailable to a large segment of our citizenry, speak out! When patient access to technology or therapy proven to be effective is denied by third-party entities merely to reduce cost, speak out!
Speak out against unethical practices in which personal financial interests override concern for the patient’s well-being! Speak out at the local, regional, state, and federal levels. Work within your own practices, your own hospitals, and in your health systems to advocate for the best cardiovascular care for your patients. Work toward the acceptance and implementation of our clinical practice guidelines, knowing that there are always exceptions to them. Support valid physician performance measures. Support the advocacy efforts of the American College of Cardiology on behalf of quality healthcare, and above all, remember to remain empathetic, caring, and compassionate as physicians. Retain your humanistic qualities no matter what the external stresses, and remain sensitive and responsive to human suffering.
In conclusion, I want to take this opportunity to recognize the great support I’ve received from my family over the years and the wonderful support and loyalty of my colleagues at the University of Virginia. Of course, we all recognize the immense contributions of the dedicated physician volunteers and the truly wonderful ACC staff who implement the vision and goals of our profession. I want also to congratulate the young investigators standing behind me for their accomplishments and congratulate the newly inducted Fellows sitting in the audience.
As incoming president of the College, I pledge to you that I will do all I can to advocate for the principles and to fulfill the goals of the American College of Cardiology—a community that many of you are joining tonight. We are a community confronted with challenge and blessed with opportunity. As we move into this new era of medicine, may all of us celebrate our past achievements while building a future of accessible, innovative cardiovascular care for the coming generation.
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Footnotes
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1 President, American College of Cardiology 
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References
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- Foot DK, Lewis RP, Pearson TA, Beller GA. Demographics and cardiology, 1950–2050. J Am Coll Cardiol. 2000;35:1067–1081[Free Full Text]
- AMA News. Groups urge focus on uninsured. June 28, 1999.
- Pear R. New York Times, November 30, 1999.
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