SPECIAL ARTICLE
A time of accelerated change in academic cardiovascular medicine
Implications for academic divisions of cardiology and their training programs
Robert M. Califf, MD*,
Thomas Ryan, MD,
Pamela Douglas, MD and
Pascal J. Goldschmidt-Clermont, MD
Duke Clinical Research Institute, the Duke Heart Center, and the Division of Cardiology, Duke University Medical Center, Durham, North Carolina
Manuscript received February 26, 2004;
revised manuscript received July 14, 2004,
accepted August 12, 2004.
* Reprint requests and correspondence: Dr. Robert M. Califf, Duke Clinical Research Institute, P.O. Box 17969, Durham, North Carolina 27701 (Email: calif001{at}mc.duke.edu).
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Abstract
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With the vast epidemic of vascular disease predicted to be the leading cause of death and disability by a growing margin over the next 30 years, academic medical centers with cardiology training programs have a special responsibility. Given the dramatic advances of biotechnology in producing highly effective but expensive strategies of prevention and treatment, cardiovascular specialists should assist their academic centers in envisioning the future to prepare trainees for a different environment. Cardiologists of the future must be able to adapt to a societal need for patient-oriented, team-based clinical care and rapidly evolving technology, while maintaining the fundamental skills and knowledge required for individual patient interaction. Academic programs should benchmark their activities to ensure responsible resource allocation so that cardiologists of the future will be trained in an environment stimulating excellence and creativity.
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Abbreviations and Acronyms
| | HF = heart failure | | NIH = National Institutes of Health |
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The problem and the opportunity
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Vascular disease is the leading cause of death and disability in developed countries (1,2). With the explosion in the numbers of elderly in the population coinciding with simultaneous epidemics of obesity, diabetes, and inactivity, this pattern will expand for the foreseeable future (3). Accordingly, as the source of cardiovascular specialists, academic cardiovascular programs and their associated training programs have a responsibility to orient their efforts toward producing specialists who can function effectively in this epidemic situation.
In the face of the global epidemic of vascular disease, we are entering an era of unparalleled opportunity to prevent and treat human disease (4), made possible by dramatic advances in our understanding of biology and engineering. Simultaneously, we are realizing that major gains could be made by more effective means of delivering existing knowledge (5,6). Paradoxically, this success and opportunity is creating the need for a different kind of cardiologist and a different approach to delivering cardiovascular care.
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The environment
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The technology that can be brought to bear by modern cardiovascular medicine is truly astounding. Medical therapy with aspirin, statins, angiotensin-converting enzyme inhibitors, and beta-blockers has produced substantial clinical benefits (7), and devices including stents (not to mention drug-eluting stents), defibrillators, left ventricular assist devices, and off-pump surgery have recently yielded dramatic reductions in age-specific death and disability rates. Diagnostic modalities are becoming more accurate and less invasive. Within the next decade we expect to see effective remote monitoring, nanotechnology producing tiny "tools" to improve health and monitor biology, and perhaps cell replacement therapy as realistic therapeutic approaches. Arrays of genes, proteins, and metabolites will be used to personalize therapy for individual patients based on specific risk assessment and expected response to therapy (8).
Partially as a result of this technology, people are living longer than ever before, and they are more functional during this longer lifespan. The current gains in longevity and functionality do not appear to be hitting a natural ceiling, but instead continue to increase. At the same time as the life expectancy of the average American is reaching beyond age 85 years, the birth rate is dropping. Within the next 30 years, the Medicare population will double, while the proportion of working people to Medicare recipients will drop from 4:1 to 2:1. This increasingly elderly population will suffer from chronic diseases, and these population trends will make vascular disease an even more dominant cause of death and disability. Simultaneously, the expectations of this older population are high, with a strong societal movement toward consumerism in healthcare, leading to a greater demand for the most current and technologically sophisticated care available.
Additionally, the increasing capability of multiple sources to measure health processes and outcomes has led to an increasingly quantifiable view of quality (Fig. 1) (9). Although the individual practitioner will continue to be appreciated and valued, the primary assessment of the value of health care will be based on independent measures focused on the system within a particular environment or "microenvironment" (10). In this context, medical quality has been defined recently by the Institute of Medicine as including six key components (safety, efficacy, patient-centeredness, timeliness, efficiency, and equitability) (Table 1). Demonstrating progress toward optimizing these measures within the cardiovascular practice and as a component of a larger health system will be an important challenge for academic centers, and training programs will need to incorporate teaching about the best ways to address these issues.
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Figure 1 The cycle of quality portrays the steps in the development of scientific constructs, evaluating them in clinical trials, constructing guidelines and performance measures based on the evidence, and measuring adoption into practice. Cardiovascular training programs should impart a fundamental understanding of this cycle into their trainees and develop training programs leading to expertise in each of the depicted areas, including measurement of clinical quality. Reprinted with permission from Califf et al. (9).
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Inevitable reality
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Over the past several decades, almost all aspects of cardiovascular medicine have undergone fundamental change. In stark contrast to the dramatic improvements in our understanding and treatment of cardiovascular disease, our approach to training physicians to practice cardiovascular care has changed little over that same period. In light of all the changes in technology, the patient population, and the health care environment, we cannot escape the conclusion that the current mode of training and practice in cardiovascular medicine is in need of systemic reform. Indeed, if expected trends for the future are not taken into account in designing today's training programs, we will face a widening gap between the needs of society and the ability of the profession to respond.
Dramatic improvements in outcome are yet to come, and these will lead to increasing costs. The impact of new drugs and devices is just beginning to be felt, but the technological revolution previously discussed will continue to bear fruit. As a result, many more people with chronic disease in general and with cardiovascular disease in particular, will be seeking access to high-quality health care. Because the incremental benefit to be achieved almost always comes at incremental cost (11,12), overall costs are likely to rise. The "slope" of this relationship between increasing cost and societal benefit will be scrutinized by payers in an attempt to rationalize the costs of new technology and to justify the extent to which medical costs can be allowed to limit other forms of societal spending (e.g., education, public safety, or defense) (13,14). Even in cases where the short-term effect is cost-saving, as in disease management programs for heart failure (HF), the end-of-life costs are simply deferred until a later time, when the aggregate costs may be higher (15). These increasing costs will inevitably increase the pressure on the decisions made by the doctor, the patient, and the payer. Rather than simply providing the same services at a faster rate, cardiovascular specialists of the future must respond by developing novel approaches to the organization of cardiovascular care.
There will not be enough cardiovascular specialists to provide services in the current configuration. After a decade or more of predictions of physician oversupply, we now have an extreme shortage of cardiovascular specialists (16–18). It appears certain over the next several years that the output of U.S.-based academic cardiology training programs will fail to keep pace with the rate of retirement and death of practicing cardiologists (17). Given what we know about the anticipated population growth and demographic changes in our society, this fact has staggering implications for the availability of cardiovascular health care in the near future. As effective technology becomes increasingly sophisticated, the ability of the generalist to keep up with the advancing technology will be even further outpaced. Even if there were a widespread increase in training slots for cardiovascular fellows, there would be no discernable impact, given the current training approach, for almost a decade. Therefore, we need to simultaneously increase the number of cardiovascular specialists and develop new models of team care that produce measurable improvements in quality at a much lower cost per unit of service delivery.
Imaging and disease markers will have a profound impact on the near future. We are nearing an era in which echocardiography will be handheld at the bedside, cardiac structure in three dimensions will be routinely accessible and transmissible over the Internet, and coronary artery obstruction will be directly measurable by noninvasive measures. Anatomic imaging will give way to modalities that provide a combination of structural and metabolic information. Such information, combined with genetic profiling, will improve our ability to tailor prevention and treatment strategies for individual patients. The expense of these imaging methods will be enormous, but they will be powerful stratifiers of risk, and they will detect disease earlier and more definitively, often in a stage that would be called preclinical today. The ability to measure the concentration of multiple proteins and metabolites at the same time will also allow for risk stratification and early disease detection; the combination of these into molecular imaging will create substantial opportunities to target therapeutics and to measure the impact of treatment on biologic pathways. Yet today's practitioners are poorly equipped to deal with this impending era of technology-based personalized medicine.
The power of newer and more sophisticated technologies will not escape our consumer-oriented society (19). The very potency of technology increases both the benefit when used appropriately and the risk when used inappropriately. Indeed, considering technologies such as mechanical or biological heart replacement places a tremendous burden on those with the technological expertise (cardiovascular specialists) to use it wisely. Given the growing presence of the Internet and the sophistication of media portrayals of these issues (20), the consumerism movement shows no sign of slowing down. Although the engagement of patients in their own care is generally an improvement, the perception of patients can be biased by societal dogma and by direct-to-consumer advertising by the medical products industry. Such expectations of intervention are also too often at the center of medical-legal conflicts. Although these problems have no easy solution, they reinforce the need for professional sources such as academic centers and professional societies to create in-depth patient education, providing a shelter from commercial bias.
Whereas the upcoming generation of trainees generally has the skills to use the Internet to their advantage, there is a gap between the possibilities of computerized learning and the current offerings. Ranging from incremental "just-in-time" updating of knowledge (21) to simulation of procedures (22–24), the possibilities for creating a more informed practitioner and a safer environment are evident. Training programs will need to take advantage of these technologic advances to reshape the long-term approach to expertise in the profession.
At the same time that the opportunities are greater than ever before, the number of people filling academic cardiology positions nationally is inadequate. Nationwide, many chief of cardiology positions are currently open, but lower-level faculty positions are even more plentiful, as the shortage of cardiologists in practice is creating a renewed widening of the income differential between academic cardiovascular specialists and those in practice. The demand for clinicians by large private groups is driving up the salaries of entry-level cardiologists, making it increasingly challenging for academic programs to compete for young talent. This phenomenon additionally threatens to limit the academic medical center as the source of future practitioners who need an environment in which to train.
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The solutions
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As we move into this technologically advanced era, training and practice must be aimed toward the construct of systems based on the cardiac care provider team, bound together by modern information systems and stimulated by the dedication of individuals on that team to improving the lifespan and function of patients through personal responsibility and teamwork. Many of the familiar routines of today's cardiologists will need to be conducted by others with more specific but limited training, while the cardiologist increasingly takes the role of "quarterback" of the delivery team in cardiovascular medicine. Rather than working in isolation as the sole dispenser of care, the cardiologist will focus more on coordinating and overseeing the array of services that constitute the health care product.
The fundamentals.
The fundamentals of bedside cardiology remain essential. For example, bedside diagnosis will be supplemented, but not replaced, by an ability to perform hand-carried ultrasound (25). Thus, pragmatic training should take place despite full knowledge that the model for practice will undergo significant change. Integrating new concepts of practice and its organization with sound teaching of today's fundamentals will be an increasing challenge for training programs. New areas of learning, from ethics to economics to clinical trial design, will be increasingly valued.
As in all of medicine, cardiovascular medicine must address the area of medical decision-making (26). Patients seek out cardiovascular specialists partially because of their technical expertise gained from repetitive performance of procedures and evaluations—the importance of volume for quality is now beyond doubt, although many other factors also contribute to quality (27)—however, advice from a technical expert about the use of powerful technology and expensive interventions is also of great importance. Despite a growing body of knowledge about the biology, psychology, and sociology of medical decision-making (28), surprisingly little is taught in medical school or beyond to assist doctors in their efforts to interact with patients, payers, and colleagues to navigate an increasingly complex array of choices.
Information systems.
Although doctors have grown weary of comparisons with airline pilots, perhaps one area where this common thinking should be embraced is in the arena of access to information. We have recently become interested in the construct that the doctor should operate in an environment similar to the cockpit of an airplane. Before the advent of the modern cockpit, pilots were becoming overwhelmed with gauges and measurements that were not organized in a standardized fashion. Largely because of a project managed by the National Aeronautics and Space Administration, the needs of pilots were meshed with the technology to produce the modern glass cockpit and the autopilot.
Academic medical centers must become the engines of change in which new information systems are developed and tested. Although we and others encourage the National Institutes of Health (NIH), the Centers for Medicare and Medicaid Services, and the Food and Drug Administration to play the role that the National Aeronautics and Space Administration did in cockpit design (that is, provide standards based on solid research), living laboratories will be needed to do the evaluations and to develop novel systems. Similar to the pilot, the modern clinician can be overwhelmed by the sheer volume of available data, varying in quality, accuracy, and relevance. More information is not always in the best interest of either the patient or the physician. To take maximal advantage of this information explosion, we must create systems that allow new data to be filtered, prioritized, and presented in context. The Internet, data-warehousing technology, and handheld devices will all play key roles in this regard. The widespread access to wireless technology, allowing images and records to be transmitted in real time, may have an enormous impact both for clinical and for research purposes. Thus, although technology per se could never be used as the primary means for quality practice, when used strategically, it will have a defining effect by producing technology-enabled clinicians rather than practitioners like those today who are limited by poor access to data that could markedly improve decision-making and communication.
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Clinical practice
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Given the critical role of cardiovascular medicine in the overall picture of clinical care delivery, top-notch academic divisions of cardiology must have excellent clinical practices. The importance of a high-volume clinical practice in the academic medical center of the future is predicated on three assumptions: 1) that the highest-quality care (29,30) can be provided in an environment in which specialty expertise is vibrant and well organized; 2) that quality is linked to volume (31); and 3) that volume is necessary to provide optimal training for residents and fellows (32).
The cardiovascular specialties are continuing to sort into well-defined subspecialties, each with a large body of knowledge and technical expertise. Interventional cardiology, electrophysiology, HF, and congenital and valvular cardiology share common characteristics. Each area will see major growth in patient volume over the next two decades, each is driven by increasingly sophisticated technology with a major impact on clinical outcome, and each is driven to further subspecialization by the complexity of the involved technology. These subspecialties also have in common the need for a firm base in fundamental clinical cardiology and an increasing use of imaging to drive diagnosis and the assessment of progression of disease.
Imaging.
The impact of imaging on cardiovascular medicine has been underappreciated. Because of its portability and low cost, echocardiography will remain the workhorse of cardiac imaging (33). Hand-carried devices will allow echocardiography to be incorporated into the bedside evaluation of the patient. In addition to confirming information gleaned through the physical examination, point-of-care ultrasound will extend bedside diagnosis to include direct measurement of left ventricular and valvular function, therefore, profoundly affecting the training of future generations of clinicians. At the same time, this trend will have important consequences on the finances of hospitals and practices. Nuclear cardiology is practiced and taught by radiologists in many academic medical centers, yet it is an integral part of the modern practice of cardiology, and in practice is predominantly performed by cardiologists. However, the superiority of magnetic resonance (34,35) for imaging both structure and function is already evident, and its potential impact on the future of diagnostic imaging is currently being shaped. Computerized tomographic angiography is likely to alter the practice of vascular medicine by offering a noninvasive method to diagnose obstructive disease on a mass scale.
Training of future cardiologists should consider both the growing variety and the increasing costs of diagnostic/imaging tools. Fellowship training for those interested in a career in imaging should provide a broad knowledge base across methods and exposure to the newest modalities. Trainees should focus less on the individual imaging techniques and more on the clinical questions. An appreciation of incremental cost, utility, cost-benefit balance, and downstream effects will be necessary for optimal use of diagnostic testing. In order for this approach to work, institutional leaders must create an environment in which experts in competing technologies are rewarded for working together, rather than one in which competition is the dominant mode.
General cardiology.
In the coming decades, perhaps no other specialist group will have more potential impact on patient outcome and societal costs than the general cardiologist. The opportunity to control the referral patterns to procedural-based subspecialists, such as electrophysiologists and interventional cardiologists, has profound implications for technology utilization. More importantly, recent studies (36–38) have demonstrated that effective primary and secondary prevention strategies have a greater potential impact on outcome than our current and traditional approaches to treating coronary disease. The general cardiologist will likely play a primary role in devising and managing individualized prevention strategies (39), relying on the Internet and other members of the integrated health care team for maximal effectiveness. With respect to training, teaching fellows about prevention is necessary but insufficient. They must also be taught how to deliver the message to a naive and often unreceptive population. In addition to communication skills with patients, fellows must be taught the role of the cardiologist as a consultant, which will continue to expand as the number of patients with heart disease increases relative to the number of cardiologists. Much more needs to be learned about the best approach to collaborative care between specialists and generalists, which has been found to be superior in some studies (40). General cardiologists can probably be trained in a short-track format to accelerate the supply situation (41).
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Directions in research
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Basic research.
Basic research in a division of cardiology has become much more complex because of the increasing interdigitation of the sciences. As described in detail by the ongoing NIH Roadmap Initiative, findings stimulated by research in one organ or tissue often have profound relevance for other systems. A key challenge for cardiology has been the prioritization of approaches to research. Training of true clinician-scientists in the cardiovascular discipline has become increasingly rare. Considering the formidable success of clinical research and consequent evidence-based medicine in the cardiovascular field, it is tempting to invest most of our physician research support at this level. This would leave PhD scientists with the large majority of NIH funding for the performance of basic research on the fundamental mechanisms of disease. Hence, very few cardiovascular physician trainees are developing expertise in studying the mechanism of disorders that constitute their discipline. We propose that abandoning basic research in the cardiovascular field may result in unwanted consequences.
Key areas of basic research in cardiovascular medicine include the now-traditional fields of receptor biology, cell signaling and atherosclerosis physiology, HF pathophysiology, and "channelopathies" (ion channel function). However, in divisions of cardiology the major source of translation will come from teams that are able to be intertwined with major institutional resources along a continuum from genomics to proteomics, metabolomics, cellulomics, transgenic models, and large animal models.
Cell therapy may have a transforming societal effect. Endothelial progenitor cells produced by the bone marrow become exhausted and/or incompetent after a lifetime of exposure of the organism to risk factors for atherosclerosis, and intravenous administration of such cells to mice has been found to improve both the process of arterial repair and that of angiogenesis for the ischemic heart (42,43). Perhaps most immediately within reach is the opportunity to resume the endogenous production of endothelial progenitor cells (44) by correcting risk factors and restoring the balance between repair cell consumption and production, such that the repair process can be completed successfully.
As new molecules (ribonucleic acids, proteins, or metabolites) are being discovered as key modifiers of disease processes, they may become not only targets for therapies, but also potential markers for the disease status. With the development of cardiovascular imaging via magnetic resonance imaging or positron emission tomography scan, such molecules, providing sufficient local concentration at the level of the diseased organs, can be tagged and localized by such high-powered technologies. Many more examples could be provided to illustrate the formidable growth of cardiovascular basic research through applied genomics and other multidisciplinary approaches. Of certainty is the fact that laboratories working along the traditional "one disease, one gene, one pathway" model are highly unlikely to make substantial contributions to our field when compared with those produced by multidisciplinary teams, despite the fact that a large fraction of the funding derived from NIH and other agencies is still targeting such investigative fossils.
Translational research (block 1).
The Clinical Research Roundtable recently identified two major blocks (Fig. 2) in translating the findings of science in societal benefit through clinical practice (45). The first of these blocks is one of the most difficult areas of research today—the initial translation from bench to bedside. At one time, this effort was in the purview of academic medicine, but over the past 25 years, the movement of intellectual property into small biotechnology and device companies has created an inefficient system by default. A recent review of this situation and a proposal to address it has been published (46,47). In essence, the future translational effort must combine creative science with expert technology transfer and highly skilled human research in an increasingly regulated environment. This effort is expensive, however, requiring significant investment in technology and people.
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Figure 2 Translational blocks identified by the Institute of Medicine Clinical Research Roundtable. Training programs should be focused on overcoming these blocks.
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Clinical trials.
Clinical trials will play an expanded role in defining effective diagnostic and therapeutic strategies, and those who pay for health care are likely to increasingly rely upon trial results expressed in the form of clinical practice guidelines to determine reimbursement criteria (48). Traditionally, participation in clinical trials, especially those funded by industry, has been regarded as a low-level academic pursuit. However, at the same time that generating and expressing new ideas and discoveries is recognized as higher-level academic achievement, academic units must be "team players" by participating in clinical trials that define effective therapies in the future. Recognizing that the best diagnostic and therapeutic strategies remain unknown represents an important step in intellectual honesty that should be the basis of an academic clinical practice. Additionally, participation in a well-organized clinical research effort provides the vast majority of trainees who will go into practice with important orientation to the organization needed to do clinical research in practice with appropriate safeguards and respect for the human subjects involved.
This role of the academic medical center as a site for clinical research has been used by many programs to triangulate money into other missions (49). For many reasons, this is not appropriate, although a modest margin can be made after appropriate investment in study coordinators, financial systems, and institutional review boards to ensure that the research is performed to the highest standards. In particular, the effort requires an organized group of coordinators rather than the "mom-and-pop" model that was often used in the past. The regulatory risk to the institution is now enormous when an uninformed investigator violates federal regulations (50,51), placing substantial value on group research efforts with professional study coordinators and sophisticated regulatory affairs and auditing functions.
As the number of clinical trials proliferates, leadership in clinical trials will be an increasingly important element of academic programs. Leading and coordinating clinical trials is distinctly different from participating in clinical trials; leaders will need to have a level of knowledge about trial design and execution that will require major investment of time and resources.
Outcomes and economics.
The basis for quality in cardiovascular practice stems from the integration of clinical knowledge, clinical reasoning, evidence from clinical trials, understanding of the organization and financing of health care delivery, and access to modern information technology that can enable measurable attainment of professional standards. Thus, the support of research and teaching efforts regarding outcome measurement and economics should be a critical part of every major training program. Training in this arena, as in clinical trials, will require a team approach including clinical epidemiologists, biostatisticians, health economists, and health services researchers. Unfortunately, this arena suffers from a major deficit in funding, both for initial training and for career development (52). Recent reviews of the topic point to the critical need for academic centers to create new approaches to sustaining clinical research professionals (53).
Translational research (block 2).
The gap between what is known about medical quality and the reality of everyday practice is increasingly recognized. Cardiovascular programs should have a program in practice improvement in which the faculty, other providers, and fellows participate. In the areas of complex HF (40,54,55), diabetes (56), hypertension (57), and lipid management (58), strong data already exist for superiority of the "cardiac team," but much remains to be learned about the best organization of delivery of cardiovascular services.
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Finances
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The complexity of academic medicine makes a simple profit-loss statement practically useless for a division of cardiology. At a minimum, the division must know the combined financial picture of the cardiac services or heart center, considering hospital, outpatient, and professional revenues and expenses. Otherwise, short-sighted efforts to maximize profitability, service, or efficiency on one side of the organization can lead to substantial unintended consequences in another part.
On the professional side, cardiovascular medicine is pivotal to the function of other specialties such as cardiac surgery, cardiac anesthesiology, and pediatric cardiology, while also providing a magnet for primary care referrals to the institution. The decline of procedural volume for coronary bypass surgery is currently placing significant stress on the professional relationships between cardiologists and their surgical colleagues, but similar stresses can occur within cardiology groups about the division of labor with regard to clinical activities with higher or lower remuneration. For example, it can be argued that concentration of interventional procedures and echocardiographic reading into high-volume operators will improve the quality of each activity for the entire division, but cardiologists who spend their time seeing patients in the clinic may work harder while generating substantially less revenue. Recognition of the fundamental dependence of one group on another is critical to optimal patient care and the long-term viability of the division. Financial and activity reports must be adequate to allow fair distribution of labor and financial gain to motivate behavior in the interest of the group.
A major issue at academic medical centers is the control of the technical fees for procedures. In clinical practice the ability to collect for technical fees for nuclear cardiology, echocardiography and cardiac catheterization in free-standing facilities is a major source of revenue for cardiologists. In academic medical centers these fees are often collected by the medical center with no direct financial return to the group that generates the revenue. Although such fees can be used to offset the extraordinary costs of the societal obligations of academic medical centers, the situation leaves academic cardiologists at a disadvantage relative to community-based practitioners and leads to a drain of effective practitioners from the academic environment and underinvestment in the clinical care system.
On the other hand, primary care physicians have legitimate concerns that the majority of vascular disease and HF is seen in primary care clinics, yet the high-revenue procedures are in the hands of cardiologists. As the national health care budget comes under increasing stress with the aging of the population, the balance of reimbursement will be fragile and unpredictable. Therefore, visionary academic centers will develop financial systems that allow sustained network-building between primary care and cardiovascular specialists, with shifting of revenue as needed to maintain both groups as financing vacillates. Ultimately, the interdependencies of the various groups must be taken into account. Just as interventionalists rely on clinic-based cardiologists for referral volume, so too do cardiologists depend on primary care physicians, not only for referrals but also for joint care of the growing population of patients with cardiovascular diseases. Although payors have tended toward an irrational approach to reimbursement that rewards the use of procedures and technology at the expense of highly effective, simple interventions, providers must see beyond their own profit-loss statement and recognize the value of a team-oriented approach to organizational finances and patient care.
The relationship between cardiology and radiology has traditionally been strained, and significant challenges are on the horizon. The issue of "control" of peripheral vascular procedures remains difficult. The revenues and reading privileges are unsettled in nuclear imaging, while echocardiography has become the domain of the cardiologist. However, the next major challenge will come as computed tomography angiography for noninvasive coronary imaging and cardiac structural assessment with magnetic resonance imaging become commonplace.
For all of these reasons, a cardiology program can make strategic financial decisions only if it has an integrated financial view of the areas under its direct control as well as the areas it affects both as a source of referrals and revenue and as a recipient of referrals and revenue.
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Assessment of a program
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Societal contribution.
Because not-for-profit academic medical centers achieve that status as a public good, the ultimate goal is to contribute to the well-being of society. Measuring societal impact is not easy, but remaining bound to the self-absorbed historical approaches to academic evaluation (publications, societies) is also probably no longer sufficient. The ideal direct measure of improved health of the local community, the country, and the world is beyond the scope of any individual cardiology group, yet measures in each sphere should take into account proxy measures for improved health outcomes.
Specific activities.
Given the complexity of the mission, the "balanced scorecard," which attempts to depict the mix of issues that must be addressed in clinical care, may provide the best measure of success (Table 1). The quadrants of the scorecard feature financial measures such as volume of patients and procedures and margin generated, and quality measures such as adherence to guidelines and patient and employee satisfaction.
Basic research is difficult to quantify, although the very top programs can easily tally measures of prestigious awards and peer-reviewed funding. A troublesome issue yet to be addressed by the NIH stems from the inability to share financial credit in joint projects within or between institutions. Table 2 lists the typical criteria used to judge the success of a basic research program.
The success of a translational research program requires new metrics, as recently outlined (46,47). Creativity in this arena will likely distinguish successful cardiovascular training programs over the next decade.
Many of the same metrics are pertinent to clinical research as to basic and translational research, although others may be different. Table 3 lists the primary criteria that may be considered. The asymmetry between the tried-and-true metrics for basic research and clinical research is striking. Whereas election to key honorary professional organizations such as the American Society for Clinical Investigation, the Association of American Professors, and the National Academy of Sciences have been successful markers of success in the sciences, these organizations have not rewarded clinical investigators to the same degree. Furthermore, impact factor as a measure of scientific publishing does not reward clinical research manuscripts to the same extent as fundamental research because of the lower density of repetitive citations. Additionally, for better or worse, the lay press remains the major source of information for the public (59), including many public-policy makers. Therefore, we are now experimenting with the use of press citations in addition to peer-reviewed publications in evaluating the impact of a clinical investigator working in clinical trials, outcomes, or population studies. Because so much of clinical research is dependent on effective teamwork, we are now including evaluation by other team members, including fellow faculty and non-faculty, in the assessment of individual quality, although this criterion is more difficult to judge for a cardiology division as a whole.
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Conflict of interest
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The large amounts of money involved in academic cardiology make it a constant source of concern about conflict of interest (60). Conflict of interest is defined as a commitment that diverts a professional from the primary commitment of the profession (in this case, service to patients). Many situations will arise in an excellent academic cardiology division that require careful personal and institutional management. A robust system for reporting and evaluating conflict of interest should be in place (61,62). A general principle is that the cardiology group should strive to lead the institution in the "transparency factor"—the degree to which financial and other transactions are available to the institutions and among faculty colleagues.
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Summary of recommendations
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- • Increase the number of cardiovascular trainees, but numbers alone will not solve the problem; a mix is needed, including general cardiologists focused on managing systems of care and subspecialists trained deeply in technology and the principles of its use. The general cardiologist may be trained in a shorter period of time, but successful researchers will require considerable protected time for training and career development.
- • Programs should strive for high volume with exemplary quality improvement efforts in their own hospitals and practices.
- • Programs should offer a spectrum of research opportunities:
- • Basic research with an emphasis on "team science";
- • Clinical trials;
- • Clinical epidemiology, outcomes, and health policy; and
- • Clinical quality research.
- • Programs should explore novel methods of delivery of cardiovascular care to produce approaches that will solve our current mismatch of cardiologists and people seeking cardiovascular care, including better linkage between practice and academic settings.
- • Programs should incorporate training about critical areas of the future:
- • Health care organization and delivery;
- • Quality measurement; and
- • Use of information technology to enable more efficient practice.
- • Specific efforts are needed to create models of lifelong learning.
- • Metrics should be used and compared to measure and improve the balanced performance of training programs.
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Abstract
The problem and the...
