Patricia A. Pellikka, MD, FASE

I have read Dr. Marty Makary’s book, Unaccountable , a disturbing, but probably not surprising account of deficiencies in the provision of healthcare in the United States. Dr. Makary, a pancreas surgeon at Johns Hopkins University Hospital and Associate Professor of Health Policy, received his medical training at some of the most prestigious medical institutions in our country. Yet, he provides a scathing insider’s critique of the actual practices at these institutions and others nationwide. He reports on the broad variation in care within a given hospital, with physicians’ recommendations for treatment, including surgery, radiation therapy, or chemotherapy, biased by their personal financial gain; popular but incompetent or even dangerous physicians retained by hospitals because of financial benefit to the institution from their surgeries, and in some cases, additional revenue brought in by complications from their poorly performed work. Makary describes unnecessary surgery endangering patients and the failure of the physicians to provide honest assessments of the risk and benefit of treatment. He criticizes the egregious fundraising practices of hospitals where CEOs earn massive salaries and lavish benefits, “40-50 times more than what they pay their nurses”, and the false advertising claims such as designations of specialty centers, when little expertise actually exists. The book is peppered with specific examples of adverse consequences experienced by completely unsuspecting patients. Dr. Makary calls for transparency and accountability in our medical systems.

Dr. Makary acknowledges a handful of medical centers at which the situation is different, and offers praise for the quality and efficiency of Mayo Clinic. Having served on the Mayo Clinic faculty since 1989, this comes as no surprise to me. Although education and research at the Mayo Clinic are important, it is a place where the patient comes first. Teamwork and collaboration prevail. Internal surveys of physician and allied health staff consistently indicate that this is the place where we would want our family and friends to receive care. Everyone, from department chairs to janitorial staff, takes pride in their work. Accountability is part of the culture.

There are outstanding and caring healthcare professionals all over the world who adhere to high standards and are accountable to their patients. The membership of the American Society of Echocardiography (ASE) is a testament to this type of inclination as our members primarily join to be engaged in our educational activities and thus, improve the care that they provide. This dedication and professionalism are why we, as a society and as professionals, take very seriously the medical literature and media reports that describe another example of lack of accountability in the medical field: overuse of diagnostic testing, including imaging. While most of these articles have focused on advancing imaging such as computed tomography, magnetic resonance imaging, and nuclear studies, echo has not been spared criticism. As we all recognize, the growing use of diagnostic imaging is largely due to its remarkable utility in the detection of disease. But there is variability in quality and utilization rates from one medical center to the next. Unfortunately, the very aspects that make echocardiography the most widely used form of cardiac imaging, its portability, ease of use and safety, may also contribute to its overuse in clinical settings. As such, we must continue to work together to develop and hone safeguards and set standards to provide the best of care to our patients, including consistency in imaging results.

Quality and accountability are important in our echo lab at Mayo Clinic; the lab has been Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) accredited since 2004. We have multiple, weekly educational conferences, and quarterly echo lab conferences that are dedicated to quality. We have a quality assurance committee for the lab and several ongoing quality assurance projects. To provide feedback for reviewers of echocardiograms, for each patient who has had both a stress echo and a coronary angiogram, the reviewer of the stress echo receives both reports for comparison. Echocardiograms are reviewed before the patient leaves the lab so that we can make sure that images are satisfactory, information obtained is complete, and the relevant clinical question has been addressed. We strive to follow good judgment and American College of Cardiology (ACC)/ASE recommendations regarding the appropriateness of testing. Such good practices are endorsed by the ASE.

The ASE constantly advocates for standardization, improved quality, and accountability in cardiovascular care. In January 2011, the organization published in JASE a Guidelines and Standards document, “American Society of Echocardiography Recommendations for Quality Echocardiography Laboratory Operations” specifying practicable, minimum standards which should be feasible for any practitioner of echocardiography. The ASE supports mandatory laboratory accreditation, provides special recognition of competency in training (FASE), and advocates for the adherence to appropriate use criteria in the application of echocardiography. Representatives of ASE contributed to the writing and review of the Appropriate Use Criteria (AUC) for echocardiography and ASE has participated in the American Board of Internal Medicine’s (ABIM) Choosing Wisely ^® campaign, naming five circumstances in which echocardiography has been commonly performed but is often unnecessary. We have developed pocket guides and teaching materials which demonstrate how to apply the AUC for echocardiography to facilitate their use by healthcare practitioners and practices. We have held an educational webinar for our members on lab accreditation and the application of the AUC in practice.

As organizations, I am glad to say that the ASE and its Foundation are accountable and true to the good mission of “excellence in cardiovascular ultrasound and its application to patient care through education, advocacy, research, innovation and service to our members and the public.” All of the money raised for the Foundation supports its education and research missions, which include medical mission trips that involve both research and education. At our board meeting at ASE headquarters in Research Triangle Park, North Carolina this past February, we reviewed ASE’s goals established at our strategic planning session a year ago. The ASE staff, along with members of the board and other volunteers, has diligently worked to realize these goals. For example, member recruitment was an important strategy, and I am delighted to report that our membership is at an all-time high, exceeding 16,000. After a detailed review of our financial situation, we considered the many projects which have been proposed and allocated funds for several exciting new ones which are aligned with our goals, including a Quality Forum in 2014, an update to our iASE guideline app, and a new educational DVD on how to perform a focused cardiovascular ultrasound study. Our dedicated board members stayed on task, contributing unique skills, personal connections, and spectacular ideas to solve problems and promote the mission of the ASE.

As you can surmise, I am proud of Mayo Clinic and the ASE, two excellent models of accountability. But there are plenty of challenges ahead. If you have not already done so, please become involved with the leadership or management of your echocardiography laboratory and volunteer to assist the ASE. Your active involvement will strengthen these organizations and make them better prepared for the future.