PROCEEDINGS
OF THE 30TH BETHESDA CONFERENCE. THE FUTURE OF ACADEMIC CARDIOLOGY.
BETHESDA, MARYLAND, OCTOBER 26-27, 1998.
JACC Vol. 33, No. 5, April 1999:1091-1135
30th
Bethesda Conference:
The Future of Academic Cardiology*
Introduction
Kenneth
Lee Baughman, MD, FACC, Conference Co-Chair, Michael
H. Crawford, MD, FACC, Conference Co-Chair
Academic
cardiology has been largely responsible for the medical advances
which have resulted in the dramatic decline in death rates
from cardiovascular disease over the last 30 years in the
United States. Changes in the health care environment including
managed care, decreased physician payment for patient care
activities, diminished industry support and a stringent regulatory
environment have had a profound effect on the academic medical
center. These changes have reduced funding for medical research
and the training of physicians and have pitted the academic
medical centers against the private sector in competition
for patients and scarce health care resources. Most academic
centers were ill equipped to deal effectively with these changes.
Consequently some have declared bankruptcy, and many are in
financial crisis. The American College of Cardiology has grown
increasingly concerned about the effect of the current environment
on the nation's academic cardiology programs. The 30th Bethesda
Conference "The Future of Academic Cardiology" was
convened to address these concerns. The conference organizers
assembled cardiologists from academic medical centers and
the private sector as well as experts from organized medicine,
industry, government and payers. The purpose of the Bethesda
Conference was not only to define market force corrections
necessary for the survival of academic cardiology, but also
to formulate a paradigm that would sustain academic medical
centers into the next millennium.
The
tripartite mission of academic cardiology is to train adult
and pediatric cardiologists, to conduct research in cardiovascular
diseases and to provide secondary and tertiary patient care.
Although all academic programs share these missions, medical
centers differ in their ability to support all of the missions
well. In addition, some are state supported, others are private
institutions, and others are hospital-based training programs
not associated with a university medical center. Thus, not
all of the recommendations put forth in this document will
be applicable to each academic cardiology program. However,
the conference did attempt to provide basic principles that
should guide the future development of academic cardiology.
Although the document is primarily directed toward the future
of academic cardiology, there may be aspects that would be
of value to other specialties and the academic enterprise.
To
sustain academic cardiology in the future, a new paradigm
must be developed within the academic medical center. This
paradigm encourages product line development and integration
across divisions and traditional departments. The product
line integration would include all three missions of academic
cardiology including patient care, research and teaching.
The product line concept would allow a seamless transition
of patients through the health care system with an integrated
approach eliminating duplication of effort and allowing cost
savings. Not only patient care resources, but also those used
for teaching, research and administration would be consolidated.
Traditional relationships would exist between product line
divisions and their academic departments for promotion, teaching
and taxation. However, some expenses previously supported
by departments would be assumed by the product line entity
and taxation reduced appropriately. Product line development
could expand to other entities within the academic medical
center such as gastroenterologic services and thoracic care.
The
conference participants strongly believed that the traditional
medical school expectations that faculty excel in all three
academic missions are no longer relevant in the current academic
milieu. The expansion of the knowledge base in all three areas,
the dedication necessary to make each area financially self-sustaining
and the effort required to stay at the cutting edge of each
of these endeavors make the individual capable of succeeding
in all three an anachronism. Likewise, the conference participants
believed that the model which demands research faculty members
make brief appearances on the wards or in the clinic a few
times a year is not an adequate model for the training and
patient care missions of the institution. Nor is the clinician
who performs a few experiments funded by clinical earnings
a useful model for advancing the science of cardiovascular
disease. Specialization in one or two of the missions is required,
and consequently most medical schools have developed faculty
tracks such as the clinician-educator, the clinician-scholar
or the research scientist.
The
conference participants believed that each of these academic
tracks should have its own criteria for evaluating faculty
performance, its own criteria for promotion and its own concept
of tenure or job security. The classic tenure track also is
anachronistic. Although the conference believed that some
element of job security was important, the traditional tenure
system should be reevaluated. A review policy to make sure
that the faculty member is still performing at the level that
originally granted them tenure and adjustment in salary or
position retention based on this review should be initiated.
Also, faculty must be trained to function as part of a team
with other health care professionals and workers. All on the
team should be respected for their unique contribution to
the enterprise and a spirit of collegiality developed. Finally,
those who attended the conference were[zzaql3] very concerned
that academic cardiology is not attracting large numbers of
women and minorities and believed that increased sensitivity
to the special needs of these groups needs to be taken into
consideration in the future academic cardiology model.
The
survival of academic cardiology is dependent on the operation
of the entity as a business. Patient care revenues which previously
were used to support the teaching and research mission are
no longer available. Specifically, budgets must be developed
to support teaching, research, patient care and administration.
Those components of the mission most in jeopardy are teaching
and the support of young investigators. The teaching performed
by the cardiovascular faculty must be quantitated and segregated
into that which is integrated into, and that which is separate
and distinct from, patient care activities. The proportion
of Medicare Part A funds intended for faculty supervision
of patient care and teaching should be directed toward those
performing these activities. Endowment funds should be raised
specifically to fund young investigators and to promote dedicated
teaching activities. There must be an alignment of the incentives
between the cardiology sections, the health care system and
the academic hospitals. This alignment may allow resources
to be allocated to cardiology sections to support appropriate
activities which directly and indirectly benefit the health
care system. Finally, it is important that the leaders of
future academic cardiology sections or cardiovascular institutes
be trained as business persons capable of understanding the
intricacies of health care finance.
A
collaborative arrangement with physicians in the private sector
is important for all three missions of academic cardiology.
The academic cardiology section needs help with teaching,
especially that performed by accomplished clinicians in outpatient
venues. Practitioners can help with the recruitment of patients
for clinical trials and other clinical research activities
that will not only increase the number of patients in the
trials, but will bring new treatments and procedures to a
broader spectrum of subjects. Finally, private physicians
can help maintain an adequate volume of patients at the academic
center to sustain its missions by helping to support clinical
activities in collaboration with the academic center. An example
of such an activity may be cardiac transplantation or a highly
specialized and investigational technique such as transmyocardial
revascularization. This collaboration should be accomplished
in a fashion that allows all involved to benefit from the
interaction, including the practitioner and his or her patient.
Some academic medical centers have developed strong collaborative
relationships with practitioners, including shared resource
and clinical care business opportunities. Although the conference
participants realized that this collaboration with the private
sector will be a challenge in today's highly competitive markets,
they believed that this is the only system that would insure
the sustained success of academic cardiology.
The
academic medical center should be preserved by the health
care system and supported by academic cardiology. Although
some of the research and teaching missions and much of the
patient care can be accomplished in peripheral institutions,
the academic medical center embodies certain features that
warrant its continuation and support. The academic medical
center's primary role is the maintenance of a milieu of research
investigation, innovation and teaching throughout all of its
activities. This milieu and collaboration has spawned many
of the discoveries that have dramatically influenced science
and ultimately, patients. This milieu cannot be maintained
in a dispersed system that does not support all three primary
missions as core objectives.
The
American public, and many involved in health care finance,
are unaware of the true cost of research and education. It
is important that the true educational cost associated with
the production of a cardiologist be accurately determined.
The value of these trained cardiologists, most of whom will
ultimately practice in the community, must be defined. The
importance of the allocation of the cost of training to the
public and payers must be justified by the value to the community.
Similarly, the rigorous nature of basic investigation and
clinical research needs to be transmitted to the American
people, who ultimately support and benefit from research investigation.
Only through such educational efforts can the support that
academic cardiology sections have received in the past be
preserved or enhanced in the future.
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