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ACC NEWS

President’s Page: On Fulfilling Our Obligations to Patients, the Profession, and Health Care Reform

(Excerpted From Dr. Dove’s Speech Given at the 56th Convocation of the American College of Cardiology, March 26, 2007, New Orleans, Louisiana)

^_* Address correspondence to: James T. Dove, MD, FACC American College of Cardiology, c/o Padmini G. Rajagopal-Moorehead 2400 N Street NW, Washington, DC 20037

I also applaud the extraordinary accomplishments of those who have served before me as ACC President. In his book Good to Great, Jim Collins wrote about turning the flywheel to get an organization started and that the flywheel gains momentum as others continue to push (1). In 1949, the founders of the ACC started to push the flywheel.

Each past President has kept it turning to make the ACC the great organization that it is for the benefit of our patients and members.

One cannot lead the College without knowledge of where it has been, appreciate the roads well traveled, and have a passion for where it needs to go. Despite the successes of the past, all of these leaders would agree that we face major challenges in health care today, and that no matter the level of difficulty, we have a responsibility to our patients and society to address these difficult issues in health care.

As I perceive it, the issues that we face fall into 4 major categories:

1 Our roles as patient advocates

2 Transformation of science to the bedside

3 Our societal obligations in health care reform

4 Our individual participation in shaping reforms

	Serving as Patient Advocate

Top Serving as Patient Advocate Transforming Science to the... Meeting Societal Obligations Get Involved References

 
We are first our patients’ advocates; however, our responsibility to patients goes much deeper than just ordering tests, conducting procedures, or prescribing medications. We have an obligation to follow through on the risk and benefits of those medications, devices, and procedures.

We have an obligation to help patients reach the goals that we have set for them in managing their lipids, high blood pressure, and diabetes. They do not understand that their hemoglobin A1C and blood pressure levels are not your responsibility, and there is no reason that they should; it is your responsibility to ensure that these are properly followed. Every physician, cardiologist or cardiovascular surgeon, advanced practice nurse, registered nurse, or physician assistant has an obligation to see that the best medicine is practiced. Doing so is not a hard thing to do. How do you want your family treated? A simple question—an easy answer. Unfortunately, that answer is not applied consistently for all patients.

When it comes to medical treatment, bare-metal stents, drug-eluting stents, or coronary artery bypass grafting, we know the limits of the data, but our obligation is to help our patients understand those choices and to guide them in their decision-making. More importantly, the decision must be what is best for each patient. It cannot be a self-serving decision. Sometimes the correct approach is uncertain because of a lack of evidence.

As physicians, we have to deal with the situation at hand. Our contract with a patient should be the same as it would for a family member. Nothing more. Nothing less.

When the evidence is not there, you and I may do it differently. Again, we must apply the family standard for the decision. The best decision must be applied regardless of a patient’s economic status, gender, race, or ethnic group. When we do not do this, we lose the patient’s confidence, as we should.

Alice Jacobs, MD, FACC, in her presidential address at an American Heart Association meeting held in New Orleans several years ago, eloquently described the loss of trust between the patient and physician and the loss of a physician’s identity when the term provider is used. It sounds more like a commodity than a compassionate caregiver.

I bristle when people talk about clients instead of patients, about profit instead of service, about volume targets instead of appropriate care—for this is the lexicon of non-clinicians.

	Transforming Science to the Bedside

Top Serving as Patient Advocate Transforming Science to the... Meeting Societal Obligations Get Involved References

 
Since 1900, we have seen life expectancy increase by more than 60%, a result of improved environmental conditions, such as sewers and water supplies, control of infection, improved surgical and medical techniques, and since 1950, a >50% reduction in cardiovascular disease mortality. While it is unlikely that we will ever again see such dramatic increases in life expectancy, it is obvious the future of medicine and our understanding of disease is bright because of advances in genomics, proteinomics, and the other "-omics."

This improved understanding of disease and the promise of personalized medicine are exciting to contemplate. However, they may raise more questions than they answer as well as raise ethical issues that are not easy to solve. Before we daydream about what might be, we need to deal with what is and consistently meet the evidence-based standards that exist.

Past leaders of the College were wise in launching the guidelines development process. Medical knowledge and advances have come to us in small doses—piece by piece—some positive, some negative, some confirming, some conflicting, some confusing, and some very confusing.

The guidelines and the thousands of people who work on them provide a valuable service for all of us. They review the literature, evaluate, compare, document, and distill the disparate information into a set of guidelines for our use. If we need to understand why a recommendation is made, we can go to the actual guideline for the explanation. For a quick reference, we have the pocket guides and PDA versions.

Those who prepare the guidelines do this heavy lifting for us, and yet too many times, we fail to deliver. Why is that? Shouldn’t a patient expect and receive 100% of the Class I recommendations every time unless there is a legitimate documented exception? Could that answer be anything but yes? And if it is not yes, then we should document the exception because failure to document raises issues in the handoff of care from one physician to the next and becomes a significant contributor to medical errors.

In 2005, I wrote an editorial in the American Heart Hospital Journal titled, "It Is Not I," referring to the failure to adhere to guidelines and performance measures (2). The retort was, "Yes, it is." The problem is that we just do not remember to do it. We think that we are doing a good job until we measure our own performance.

Some physicians have developed paper tools to help them adhere to basic performance measures. In a hotel stay last year, I found a maid’s checklist, which identified that the linens had been changed, the bed made, the floor swept, and so on. We know that airline pilots follow checklists before moving the plane from the gate. Why don’t we do that? Being busy is not a satisfactory excuse.

Today, we need to examine the electronic tools—paper tools are like an abacus or slide rule. They work, but with information technology, we can do better. Why do we resist information technology in our practice setting when we embrace other technological advances in the care of our patients? We know its value in achieving quality care. Continued resistance is unacceptable and not defensible.

We can and must do better.

	Meeting Societal Obligations

Top Serving as Patient Advocate Transforming Science to the... Meeting Societal Obligations Get Involved References

 
We have a societal obligation to weigh in on the health care reform debate and a societal obligation to use medical resources responsibly. Some claim that we cannot advocate for societal benefits and the patient at the same time. I say: yes, we can. We have a duty to engage in reform of the health care system.

Some claim that we do not have a system, but we do, and it is built on a handmade product format. Its motto is: one patient at a time.

It is an asset of personal, patient-centered care, but it is a failure if we measure the system for meeting specifications, efficiency, access, and coordination of care. We recognize and understand these deficiencies better than anyone else involved in health care, including the insurers, government bureaucrats, and business executives.

Because we understand the system best, we must step up to the plate to preserve what is good about this handmade product while correcting its deficiencies.

It is certain that our health care system will change. Some physicians would prefer to sit in the back of the room and hope they are not called on. That is not an option in this debate. Look at what has happened in just the past 5 years. How much time and how many dollars have we spent on the sustained growth formula (SGR)? Everyone agrees the formula is bad, but it still has not been changed. We will be overwhelmed with bad policy if we are not at the table.

I have read some of the testimony on alternatives for the SGR. Quality of care is left out of the equation. Suggested changes ignore the appropriateness of care and fail to understand how medicine is practiced. They do not understand the caring side of medicine and only address the need to control costs. They propose ideas about controlling costs that will compromise quality.

Silence is not an option. We must be there to defend our patients and our members. Our position cannot be self-serving but must be based on access to appropriate quality care. We also have an obligation to control costs in every way that we can. "I do it this way because it is my way," is not an acceptable retort. We must be one of the leaders in the debate on health care reform.

	Get Involved

Top Serving as Patient Advocate Transforming Science to the... Meeting Societal Obligations Get Involved References

 
The time has come for all of us, young and old, to get involved in this reshaping of our health care system. At the very least, practice good medicine and do all that you can personally to follow the guidelines and meet performance measures while ensuring that your practice partners and staff do the same. Other steps you can take include:

• Follow the Institute of Medicine’s 6 principles of quality care: effective, efficient, safe, timely, patient-centered, and equitable care

• Adopt technology that promotes adherence to guidelines and performance measures

• Embrace the cardiac care team concept and work closely with the primary care physicians to foster patient understanding, compliance, satisfaction, and health

• Get involved with your state chapter. Chapter involvement is an important benchmark for subsequent ACC national service.

• Volunteer for committees, task forces, advocacy groups, and quality initiatives

• Respond to health care issues in your state.

In general: get involved and think of solutions. Complaints without involvement ring hollow. We have work to do. I look forward to working with you this next year and addressing these complex issues. Thank you for the opportunity to serve as your President.

	References

Top Serving as Patient Advocate Transforming Science to the... Meeting Societal Obligations Get Involved References

 

1. Collins J. Good to Great: Why Some Companies Make the Leap & and Others Don’t. New York, NY: HarperBusiness; 2001.
2. Dove JT. It is not I Am Heart Hosp J 2005;3:48-49.[CrossRef][Medline]

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