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 3: Teaching
Gabriel
Gregoratos, MD, FACC, Co-Chair, Alan B. Miller,
MD, FACC, Co-Chair
CARDIOLOGY
TEACHING AND THE CHANGING HEALTH CARE SCENE
Teaching
is the process whereby knowledge is transmitted from
teacher to student. In the medical arena it takes place
at multiple development levels (medical student, resident,
cardiology fellow, practicing physician and nonmedical
health care personnel) and at multiple sites and venues
(medical school, hospital, clinic, office, invasive
and noninvasive laboratories, professional conferences,
bedside rounds and small group discussions). Scholarly
teaching is a fundamental objective of the academic
cardiology unit (1).
The
teaching of cardiology is critically important in an
era of rapidly developing new technologies for the diagnosis
and treatment of cardiovascular diseases. The clear
communication of information to all levels of trainees
has major implications in patient care. Scholarly teaching
can best be coordinated by clinician-educator faculty
in the academic cardiology unit, who have the knowledge
base and understanding of the ties between basic and
clinical investigation to balance bias and anecdotal
experience with science and evidence- and outcome-based
research.
In
the academic cardiology program of the future, teaching
will be increasingly evidence-based rather than experiential.
Teaching evidence-based cardiology within an integrated
health care delivery system adds value to the system
from the standpoint of payers, community providers and
other internal customers. Because cardiovascular disease
represents a ubiquitous and costly component of population-based
health care, the value of the academic cardiologist
as an educator and organizer of evidence-based guidelines
and quality management systems should be obvious to
health systems and other medical care enterprises. The
development of value/outcome standards for the teaching
contributions of cardiologists to these systems will
be a major objective of the academic cardiology units
of the 21st century.
The
substrate for clinical teaching of both internal medicine
and cardiology has undergone major changes in the past
three decades as a result of the Medicare Act of 1965
and the emergence of managed care in the 1980s (2).
Although major regional differences exist, these changes
have had considerable impact on the clinical teaching
of both internal medicine and cardiology (3,4).
There
has been a major shift of clinical care to the ambulatory
setting, and fewer admissions to hospitals solely for
diagnostic workups. Hospitalized patients tend to be
sicker, and the ratio of intensive and "intermediate"
care level patients to stable, less complicated patients
is high. As a result, the total care of these patients
has become more and more fragmented; in the inpatient
setting, residents and cardiology trainees have much
less opportunity to exercise clinical judgment, consider
differential diagnoses and develop long-term management
plans. For example, patients with post-myocardial infarction
cardiogenic shock are usually taken to the catheterization
laboratory early in their course and revascularized
either percutaneously or in the operating room rather
than remaining in the critical care unit for hemodynamic
monitoring and circulatory support. There is an increasing
number of inpatients with end-stage congestive heart
failure being evaluated for cardiac transplantation--a
highly specialized process in which trainees may not
actively participate. Disease states have also changed
dramatically. Patients with rheumatic valvular disease
are rare, whereas patients with coronary artery disease
and heart failure predominate in both hospitals and
clinics.
The
demands of managed health care systems mandate that
patients admitted to hospitals stay for shorter periods
of time. This rapid turnover results in a disproportionately
higher number of admissions compared with several decades
ago. The combination of a larger number of admissions,
sicker patients and rapid patient turnover increases
the workload of academic cardiology faculty and has
an adverse impact on the training experience of medical
students, internal medicine residents and cardiology
fellows.
Faculty
time available for teaching has declined in the past
20 years. There are several reasons for this, as indicated
above, but increasing clinical effort is the major one.
Additionally, the requirements imposed by various health
care systems for precise documentation of faculty involvement
with patient care has progressively increased (5).
Thus, time previously spent by faculty in teaching is
increasingly taken up by documentation requirements
for reimbursement, and by frequent visits to patients.
Furthermore, clinician-educators are frequently required
to perform additional activities such as teaching of
generalist physicians and nurses, participating in marketing
processes and outreach and performing administrative
tasks relating to practice issues.
The
changes in the clinical spectrum of patients and acuity
of illness coupled with reduced faculty time for teaching
form the basis for the current concerns regarding the
teaching of cardiology (6).
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