ACC NEWS
President's page: The practice of medicine: Many hands, light work
Michael J. Wolk, MD, FACC, President, American College of Cardiology*,*,
Alan Brown, MD, FACC* and
James T. Dove, MD, FACC*
* Address correspondence to: Michael J. Wolk, MD, MACC, 520 East 72nd Street, New York, New York 10021.
We are navigating an extraordinary sea of change. On the one hand, we face incessant waves of progress, where medical knowledge is doubling every five years. On the other hand, we are struggling to gain solid footing against perennial specialty turf battles, dwindling health care provider supply, malpractice liability, increasing overhead, and zero-sum gain reimbursements.
Patient care has subtly shifted from oversight and comfort measures to "miracle" pharmaceuticals, procedures, and devices that dramatically help patients but also lead to complex issues of appropriateness of use and potential to harm. Add in life-threatening lifestyles that have produced epidemics of diabetes and obesity, and we see a gradual unraveling of public health gains made over four decades of smoking reduction. Plotted against current rates, data indicate that by 2050, every American will be overweight, and by 2100, every American will be obese (1).
What does this mean to those of us practicing everyday cardiovascular medicine? Simply put, we need to rethink our approach. We must adopt a more systematic, broad-based community response to disease management and prevention while simultaneously caring for individual patients. We suggest these seemingly opposing goals can be achieved through one existing entity: the cardiac care team.
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Deploying the cardiac care team
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One obvious way to divide and conquer expanding community need is via a well-coordinated cardiac care team. Research shows that, in the past, a single doctor attempting to follow appropriate practice guidelines for his or her patients was successful only about 10% of the time (1). With new technologies, research, and effective teamwork, we can realistically expect to achieve the highest modicum of compliance with established practice guidelines for more than 80% of our patients (1).
The scientific basis of the care we can provide is greater than ever before, but we have to develop better systems to deliver it. Reliance on memory is not good enough, and the scope of care is beyond the capacity of an individual physician. Best practice covers not just adherence to clinical guidelines, but runs the entire gamut of care from prevention to diagnosis, treatment, patient compliance, and education.
Disease management teams are projected to become the norm, swiftly providing multi-pronged patient care designed to abort catastrophic cardiovascular incidents. Cardiac care teams will be charged with the task of efficiently combining the skills of physicians, nurses, clinical nurse specialists, nurse practitioners, physician assistants, exercise physiologists, endocrinologists, pulmonologists, nephrologists, social workers, dieticians, and other professionals. By creating economies of time and talent—and adopting state-of-the-art digital supports like electronic health records— more people can be treated in more highly personalized ways.
For example, instead of one physician scrambling to see 30 patients a day in the office, a nurse practitioner or physician assistant will be assigned to manage routine patient needs. These highly qualified and specially trained team members can review patient charts, prepare notes, and make care recommendations. Patients will be able to receive much of their clinical care, education, counseling, and follow-up from non-physician members of their care team, with the doctor serving as an expert advisor providing the underlying knowledge and philosophy of care (2).
This holistic approach to patient care extends into the home, where patients are expected to be compliant with challenging cardiovascular care protocols in a sometimes hostile environment. Cardiac care team members can make frequent check-up calls, arrange for home electronic scales, and order home health support, if necessary.
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The learning curve
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As cardiac disease management teams become synonymous with quality care for the individual and the masses, cardiologists must become multidimensional managers. We will need to acquire knowledge and practical skills in the fields of technology, human resources, motivation, delegation, process management, and leadership.
The American College of Cardiology (ACC) has acknowledged the critical role of the cardiac care team through its Cardiac Care Associate (CCA) member category introduced in January 2004. In less than one year, more than 1,400 nurses, clinical nurse specialists, nurse practitioners, and physician assistants have joined as ACC members. It behooves each physician to encourage and facilitate CCA membership of his or her staff in the College. Such tangible action on the part of physician-leaders will be central to confirming CCAs as indispensable cardiac care team members.
By bringing cardiac care team professionals on board as full-fledged College members, the ACC is setting a course to provide the education programs and training products required to move the entire team forward. Already, the College has begun to design best practice protocols for cardiac care teams to ensure appropriate elements of care are delivered by the right team member. In addition, plans are in place to develop clinical practice guidelines for systematic team care that strongly encourages task-oriented functioning of cardiac care team members.
Partnerships are being forged by the ACC to address the multidimensional practitioner's needs. The Interventional Task Force, for example, is working closely with the Society for Vascular Medicine and Biology (SVMB) to develop programs to support vascular medicine and endovascular certifications. The ACC also is enhancing its relationship with the Medical Group Management Association (MGMA) to bring practice and personnel management information to our members. In 2005, our diabetes curriculum toolkits will be distributed to state chapters, and the first step of the cholesterol management clinical system is available now on Cardiosource (3).
Meeting community need in the very near future will force reliance upon the premise of "many hands, light work." While a multi-layered cardiovascular practice model is not new, elevating the cardiac care team to a physician-peer level in regards to clinical patient care is a paradigm shift. We can no longer afford the luxury of pecking order and ego gratification in the face of what is coming. Instead, we must whole-heartedly embrace our new position as a developer of positive patient management systems. Only united will we stand.
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Footnotes
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* Throughout his Presidential year, Dr. Wolk will present ideas important to College members, in collaboration with key ACC leaders and staff. 
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References
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- Prevention in Children is Best Option to Combat Obesity Epidemic: Expert Says Climbing Youth Obesity Rate Leading to Largest Public Health Crisis in History. American College of Sports Medicine Press Release, April 10, 2003. Available at: http://www.acsm.org/publications/newsreleases2003/foreytobesity041003.htm. Accessed November 17, 2004..
- Lambrew CT, Dove JT, Friday BA, et al. Working group 5: innovative care team models and processes that might enhance efficiency and productivity. J. Am Coll Cardiol 2004;44:251–5..
- Current Clinical Collection of Cholesterol Management. Cardiosource. Available at: http://www.cardiosource.com/study/clinical_collections?page=chol_chol.htm. Accessed November 17, 2004..
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Deploying the cardiac care...
The learning curve