Is Clinical Excellence in Cardiology Different from Clinical Excellence in Other Specialties?

In no other field of medicine has there been so much work on performance measures and guidelines, with numerous statements published by the American Heart Association and the American College of Cardiology. Performance measures in cardiology have been created for the treatment of acute cardiac conditions in the inpatient setting and for outpatient management of coronary artery disease, heart failure, and atrial fibrillation. Compliance with these performance measures has been monitored in the inpatient setting (i.e., with the National Cardiovascular Data Registries and Get With the Guidelines ) and outpatient arenas (Practice Innovation and Clinical Excellence ). Despite the effort that has gone into developing guidelines and consensus statements in cardiology, the link between compliance and clinical excellence has not been clearly demonstrated. For example, the compliance of hospitals with performance measures is not associated with improved heart failure outcomes. The speed with which an interventional cardiologist achieves reperfusion of the culprit vessel, the so-called door-to-balloon time, is an important performance measure in the treatment of patients with acute ST-segment elevation myocardial infarctions. However, a recent study of 8,771 patients with ST-segment elevation myocardial infarctions who underwent primary percutaneous coronary intervention showed that although median door-to-balloon time decreased, and the percentage of patients with door-to-balloon times <90 minutes increased from 2003 to 2008, in-hospital mortality did not change during that time period, even after controlling for baseline characteristics.

Excellence in clinical cardiology may differ from clinical excellence in other specialties because the things cardiologists do are different from the things other physicians do. Like other specialists, cardiologists use their medical knowledge and skill to improve the health of their patients, but cardiologists also “have the tools to alter the course of the disease.” Cardiologists perform or supervise a variety of invasive and noninvasive procedures not generally performed by other specialists. Differences in scope of practice and the plethora of guidelines and consensus statements in the field of cardiology create a different context for clinical excellence in this specialty. The 7 domains of clinical excellence previously described are discussed individually with this special context in mind.

Communication and Interpersonal Skills

Communication and interpersonal skills are critical to many aspects of the patient-physician interaction in cardiology, as they are in other disciplines. These skills are particularly relevant to behavioral counseling in preventive cardiology. One of the main roles of the cardiologist is to advise patients to adopt behaviors that promote heart health and to avoid others that do not in a way that is clear, useful, and respectful. Unfortunately, cardiologists may be lacking in their interpersonal skills and often demonstrate only moderate interest in educational interventions that pertain to cardiovascular risk reduction. Hayes et al concluded that “cardiologists demonstrate areas of weakness in core competencies as reflected by the American Board of Medical Specialists that involve patient care and interpersonal communication skills.” Particularly disappointing is the finding that cardiologists often lack knowledge, interest, and commitment to communicating with patients about smoking cessation. Indeed, many cardiologists do not consider themselves the most appropriate individuals to communicate with patients about quitting. Clinical excellence in cardiology is dependent on communication and interpersonal skills in all patient encounters, something that is perhaps most evident when making recommendations to reduce cardiovascular risk.

Communication and Interpersonal Skills

Communication and interpersonal skills are critical to many aspects of the patient-physician interaction in cardiology, as they are in other disciplines. These skills are particularly relevant to behavioral counseling in preventive cardiology. One of the main roles of the cardiologist is to advise patients to adopt behaviors that promote heart health and to avoid others that do not in a way that is clear, useful, and respectful. Unfortunately, cardiologists may be lacking in their interpersonal skills and often demonstrate only moderate interest in educational interventions that pertain to cardiovascular risk reduction. Hayes et al concluded that “cardiologists demonstrate areas of weakness in core competencies as reflected by the American Board of Medical Specialists that involve patient care and interpersonal communication skills.” Particularly disappointing is the finding that cardiologists often lack knowledge, interest, and commitment to communicating with patients about smoking cessation. Indeed, many cardiologists do not consider themselves the most appropriate individuals to communicate with patients about quitting. Clinical excellence in cardiology is dependent on communication and interpersonal skills in all patient encounters, something that is perhaps most evident when making recommendations to reduce cardiovascular risk.

Professionalism and Humanism

As is true of other specialties, professionalism and humanism are critical aspects of clinical excellence in cardiology and central to the public trust in cardiologists. However, the benefits that clinicians in this specialty derive from having “the tools to alter the course of the disease” are accompanied by unique threats to professionalism that may be posed by purveyors of those tools. The pharmaceutical and device-manufacturing industries are major sponsors of research in cardiovascular disease and spend large sums of money promoting their products to cardiologists. In 2005, 73% of medical device funding targeted cardiovascular disease, and stories about how relations with industry may affect the practice of cardiologists and erode the public trust are now common in the lay press. In a recent national survey of physicians, most respondents surveyed reported physician-industry relations, and cardiologists led the way. In a recent poll conducted by Consumer Reports , >3 in 4 individuals reported that they would be “very” or “somewhat” concerned about receiving the best treatment or advice from a doctor who accepted drug company money. Several years ago, the American College of Cardiology Foundation and the American Heart Association jointly published a document based on a conference that highlighted potential conflicts of interest facing cardiologists. The authors of the document asked the question, “What are the issues in modern cardiovascular care that create real or potential problems of conflict of interest for our members and for the organizations themselves?” They compiled several task force reports that addressed issues related to professionalism of special relevance to cardiologists. Given the unique threats to professionalism in cardiology, as well as the special trust patients place in us to protect such a critical aspect of their health, professionalism and humanism are certainly important domains of clinical excellence in this specialty.

Diagnostic Acumen

A recent report by Hector Ventura in The American Journal of Cardiology memorializes Dr. Kenneth Baughman, who died in an accident on an early morning run while attending an American Heart Association meeting. It is hard to think of diagnostic acumen in cardiology without his image coming to mind. Cardiologists with great diagnostic acumen are those who demonstrate superb skill at integrating information from the history and physical examination and solving the clinical puzzles that confront them. They are the individuals whom other cardiologists turn to with diagnostic dilemmas or when they just do not know what to do. The report on clinical excellence by Christmas et al suggests that an important part of diagnostic acumen is being “right.” Almost all cardiologists can think of someone whom they routinely turn to for help and who always seems to be “right.” For many, Ken Baughman was that person.

Skillful Negotiation of the Health Care System

Like other specialists, cardiologists must have an understanding of the health care system to deliver appropriate care to their patients. Health insurance benefits, medication costs, and disability determinations are all important to the care of patients with cardiovascular disease. Skillful negotiation of the health care system is a particularly critical aspect of clinical excellence in cardiology to demonstrate when treating older patients with heart failure and multiple co-morbidities, especially near the end of life. Although heart failure guidelines recommend that patients with the most advanced stage of heart failure be considered for hospice care, patients with heart failure are rarely referred to hospice. Only about 1 of every 10 patients in hospice has a primary diagnosis of heart failure. Compared to other subspecialists who regularly deal with patients at the end of life, cardiologists appear to have little skill in negotiating the health care system to the advantage of their patients. Cardiologists are less likely than oncologists or primary care physicians to report having working relations with hospice. This may be because cardiologists may have neither training nor comfort with end-of-life care. Clinical excellence in cardiology most certainly involves skillful negotiation of the health care system for all patients, and this is particularly important when caring for patients with refractory heart failure who are near the end of life.

Knowledge

Superior knowledge is a “requirement” of clinical excellence that involves knowledge of the research in one’s specialty and also in related fields. Cardiology is replete with practice guidelines and a mass of published research reporting the results of clinical trials, but the knowledge that forms the foundation of clinical excellence in cardiology must go beyond simply demonstrating a command of the published medical research.

Approximately 10 years ago, Dr. Carl Leier, a renowned heart failure expert, was asked to be a guest editor and to select a theme for an issue of the journal Congestive Heart Failure . Acknowledging the plethora of reports already in existence on heart failure guidelines and evidence-based cardiology, and recognizing the wisdom that can be derived from master clinicians, Dr. Leier noted that “it is remarkable how much of the day-to-day medical care of the patient with heart failure has not yet been addressed by statistically powered (i.e., evidence-based) trials.” Dr. Leier sent a note to a group of master clinicians in heart failure management, asking them to contribute “helpful tips, suggestions, maneuvers, and approaches that have been helpful to you (and your patients) over the years in the evaluation, management, and therapy of [congestive heart failure].” His invitation “targeted physician-scientists with at least 2 decades of heart failure experience, a significant publication record of peer-reviewed investigation in heart failure, and known, masterful clinical expertise in human heart failure at the bedside.” From the responses to his invitation came clinical “nuggets, pearls, and vignettes” that are extremely insightful and helpful to individuals who provide care for patients with heart failure. Most of the information contained in the quotations from these master clinicians would not be able to be gleaned from heart failure trials or clinical guidelines. It is the wisdom gained from experience caring for patients with heart disease over many years that is a critical aspect of clinical excellence in cardiology.