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*
Task
Force 1: Clinical Care
Henry
DeMots, MD, FACC, Co-Chair, Gilbert H.
Mudge, Jr., MD, FACC, Co-Chair
ADVANTAGES
OF ACADEMIC MEDICAL CENTERS
Despite
considerable challenges confronting academic medical
centers in the immediate future, such centers
have unique capabilities/strategic advantages
that should be used to confront the challenges.
These advantages can enhance the opportunities
for integration of research, teaching and clinical
care while providing incentives for potential
relationships with community providers.
Expertise.
Academic medical centers are capable of providing
a broad spectrum of expertise that should provide
for unique capabilities in innovation of clinical
care. Some subspecialists may be used in the evolution
of critical pathways, product line development
and restructuring of clinical care models (8).
Moreover, the depth of expertise may make reorganization
across product lines more feasible in an academic
medical center than in the traditional context
of specialty health care providers. In many locales,
academic programs offer unique expertise in high
risk angioplasty, congestive heart failure/transplantation,electrophysiology,
adults with congenital heart disease and cardiac
genetics.
Application
of basic research to clinical practice. The
opportunities for translational research from
basic science to the bedside represent enormous
growth opportunities for academic medical centers.
Indeed it is the opportunity to link sophisticated
investigator-initiated biological research with
clinical expertise that most strongly differentiates
the academic medical center from community providers
and industry. Recent basic research discoveries
have led to novel therapies that include, but
are not limited to, brachytherapy for restenosis,
percutaneous transmyocardial laser revascularization
to stimulate angiogenesis and vascular endothelial
growth factor (VEGF) for peripheral vascular disease,
and the promise of gene transfer technology presents
unique opportunities for academic medical centers
to expand their clinical responsibilities. Alignment
between industry and academic medical centers
in translational research provides enhanced opportunities
for academic medical centers to market themselves
as the providers of true quaternary care to a
knowledgeable and discerning patient population.
Moreover, the American patient population continues
to demand access to specialists who are capable
of the most sophisticated medical care. The alignment
of the academic medical center to industry represents
an important strategic advantage in this regard.
The
academic medical center needs to be more aggressive
at protecting and developing the intellectual
property of its faculty. This will clearly be
a source of future revenue during this time of
rapid growth in biomedical and genetic engineering.
If patents can be licensed to companies in the
same geographic region as the academic medical
center, that can be of benefit to the local community.
If faculty are encouraged to develop companies
so that patents they develop can be licensed back
to faculty companies, additional methods will
be created to fund research as well as maintain
faculty in the academic medical center.
Academic
medical centers that have successfully partnered
with community physicians possess a unique opportunity
to enroll large numbers of patients in industry-sponsored
trials. Academic medical centers often possess
the opinion leaders who provide the impetus to
these trials, and whose participation in the design,
implementation and data analysis of these trials
is of importance. Better marketing of these two
advantages by the academic medical center to industry
can also serve as a revenue source in the future.
However,
when industry is the initiator of new drugs, biologics
or devices, the academic medical center is often
not the partner they currently seek for initial
patient trials. Recognized expertise is in the
community, the overhead costs are often lower
and bureaucratic obstacles are typically less
burdensome. The academic cardiology division cannot
afford to surrender this traditional relationship
with industry and must continue to compete for
clinical studies generated from basic science
work performed in industry.
Organizational
structure. The organizational structure of
academic medical centers might suggest that there
can be a closer alignment of purpose between faculty,
hospital and medical school than in the community
hospital with community specialists. This potential
alignment is not often strategically explored,
as traditional agendas have been perpetuated.
Administrative
structure. An important advantage of the academic
cardiology program is that the practitioners within
the academic medical center have defined leadership
and are used by a single entity. This structure
is in marked contrast to nonacademic medical centers
that must contend with multiple group practices
and which often have unwieldy bylaws requiring
a majority vote to enact any new practice patterns
or to establish contractual relationships with
insurers. Furthermore, it provides a mechanism
by which physicians can be given incentive to
maintain a relatively consistent practice pattern
and to comply with new practice guidelines.
Brand
equity. The American population will continue
to demand access to specialty care. This is manifest
by point-of-service options, plateau enrollment
in heavily controlled managed care plans and continued
requests for subspecialty services. The brand
equity that academic medical centers bring to
specialty care has not been sufficiently exploited
by many centers. Patients will never want to be
excluded from the "court of last resort,"
and academic medical centers are in the unique
position of providing such quaternary care. In
addition, evidence of patient concern about not
being able to choose their own physicians is responsible
for the negative backlash against Health Maintenance
Organizations appearing in recent U.S. congressional
campaigns.
Information
systems. Whatever occurs in the evolution
of American medicine, information system capabilities
will be central to the long-term success of health
care providers. The integration of information
systems with clinical care, medical management
and any prospective payment system will occur.
Academic medical centers may be in the unique
position to take a leadership role in the evolution
of such information systems that integrates inpatient
and outpatient activity and larger system approaches.
In the short term, community providers may have
more relevant information systems that address
their day-to-day needs. The academic medical center
also has had a traditional mission to provide
access to computerized reference services and
innovative educational material, but the widespread
availability of Internet services has deeply discounted
this traditional role.
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