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
CORRECTIVE
MEASURES
Better
transition to an outpatient model. Over the past
several years, an increasing proportion of clinical
cardiac care has been conducted in ambulatory care settings
rather than in hospital inpatient facilities. This is
evident by the 10% to 20% decrease in the number of
bed days of care over the past 2 years. Increasingly,
specialized cardiac care is being provided to ambulatory
patients, and procedures such as transesophageal echocardiograms
and cardiac catheterizations are now routinely performed
on an outpatient basis. In addition, the recent proliferation
of chest pain units to evaluate patients with acute
chest pain often obviates the need to admit patients
who, in the past, were admitted to a telemetry or coronary
care unit.
Thus,
strategies must be developed to educate medical students,
house staff and cardiology fellows in this changing
health care arena. It is important for the academic
cardiology unit to determine what clinical sites are
most appropriate to be used in teaching different segments
of the curriculum so that students and trainees are
able to practice in settings where patients actually
receive their care. The issues for cardiology teaching
are the same for general medical education, that is,
1) Where should the sites be located? Should they be
centralized or dispersed? 2) What resources will be
required? and 3) What are the finances of the ambulatory
sites and how should these costs be split among the
various involved parties which include the cardiology
unit, the departments of medicine or pediatrics, the
medical school, the hospital and the insurer?
Enhanced
prestige of teaching. A faculty appointment in the
cardiology division of most medical schools includes
an obligation to teach. Teaching efforts are generally
monitored by the departments of medicine or pediatrics
and/or the cardiology division, although the process
is not well defined and varies widely from institution
to institution. In the case of volunteer faculty, this
appointment usually offers no compensation. Thus, rewards
for teaching must be developed and must be administered
with fairness and equity.
For
full-time faculty paid by the medical school, a different
issue arises, namely, the protection of income of faculty
who teach extensively and who therefore give up valuable
research and clinical practice time. Because the clinical
faculty now have increased demands on revenue generation,
they have less time to teach medical students, house
staff and cardiology fellows. This is especially true
in cardiology divisions, which often generate large
amounts of money and which are called upon to support
not only themselves but also less "profitable"
divisions within the parent department. Some studies
have suggested that faculty who are simultaneously seeing
patients and teaching students and trainees have decreased
clinical productivity. Although this is not unexpected,
it becomes a difficult issue because of increased demands
for greater efficiency and cost containment, particularly
by managed care programs. Thus, for full-time faculty
members, the time spent teaching represents a true opportunity
cost. It is becoming increasingly difficult to subsidize
the teaching faculty as departmental and divisional
surpluses disappear, yet not to do so endangers not
only the academic mission, but also the entire definition
and role of the profession.
Innovations
in teaching methods and evaluation techniques. There
is widespread perception that cardiology teaching today
emphasizes technology to the detriment of basic clinical
skills (see above). It is therefore necessary for program
directors to take bold and innovative steps to redress
this anomaly. Ideally, clinical cardiology teaching
should be the responsibility of the "general"
or "clinical" cardiologist who would teach
the "approach" to diagnosis and management
of cardiovascular disease. A specific aspect of the
patient's diagnosis/management could subsequently be
turned over to a technology-based cardiologist who would
(in this setting) have the opportunity to impart his
knowledge to the trainees.
The
academic cardiology unit of the future must also embrace
new ways of conducting "teaching" and "work" rounds.
A major issue is that of continuity of patient care
and teaching experience of faculty. The "occasional"
teaching attending physician experience will gradually
diminish and teaching will be conducted by faculty dedicated
to this activity. Similarly, new ways of conducting
efficient and effective teaching rounds need to be tried
and implemented. Combining effective teaching with efficient
patient care will be the measure of a successful teaching
program in the future.
The
lack of adequate patient volume with characteristic
valvular physical findings (see above) can be and should
be corrected with the more widespread use of modern
teaching tools: audio tapes, video tapes, "Harvey"
mannequins, interactive computer software and so forth.
Although many of these aids are available, their use
has not been integrated in the day-to-day teaching of
clinical cardiology (13,14).
Finally,
each training program could conduct its own examination
of the clinical skills of the trainees akin to the "in
service" examination internal medicine residents
are required to take. Such an examination would help
the trainees ascertain their weaknesses and help the
program director assess the quality of the training
program.
Financial
support. Graduate medical education funding has
traditionally been financed from a variety of sources
including Medicare, training grants and faculty practice
plans. With the exception of Medicare, it is often difficult
to quantitate the precise magnitude of such support.
In fiscal year 1996, for example, Medicare spent $6.6
billion to support costs related to training students
and residents. Medicare payments to support graduate
medical education are divided into two major components:
direct and indirect graduate medical education. Direct
graduate medical education funds are payments made by
Medicare directly to teaching hospitals based on 1984
historical costs to cover the salaries for residents,
supervisory personnel and other associated costs to
maintain a residency program. A payment is made for
each full-time resident; for some subspecialty residents,
the payments are down-weighted to provide disincentives
for this type of training. Indirect graduate medical
education funds are not based on identifiable costs.
Rather, they are intended to support teaching hospitals
and to compensate them for the higher costs that training
programs incur. Thus, indirect graduate medical education
payments are meant to compensate for the fact that sicker
patients are generally admitted to teaching hospitals,
that additional tests are often ordered and that special
care units are required. Hospitals are paid indirect
graduate medical education costs through annualized
Division of Research Grants payments. In addition, Medicare
payments provide funds to pay supervisory physicians
(Part A) and for services rendered directly by full-time
and private practice physicians.
In
some cases, Medicare payments are capitated, in that
hospitals receive a per capita prepaid premium. This
is a negotiated rate unrelated to actual services consumed,
and this payment usually includes the graduate medical
education funds. The Institute of Medicine, in its April
9, 1997 report, identified several issues for future
funding by governmental programs. These points include
1) continued desirability of graduate medical education
funding, 2) the need for relative neutrality of the
payments in trying to shape the workforce, 3) the need
for each payer to contribute proportionately to support
graduate medical education, 4) the need for reasonably
consistent payments across different institutions, and
5) the need for transition to any new distribution scheme
to be gradual and nondisruptive (15).
The
Institute of Medicine's plan is also noteworthy in that
it suggested the use of a defined fund to support graduate
medical education which is separate from the Medicare
Division of Research Grants payment system and from
capitation. Further it does not attempt workforce restructuring,
it sets a uniform price per trainee and it is more responsive
to possible future changes in health care delivery.
In
contrast, private sector payers are under pressure to
control costs; this has caused many such payers to deny
payment for training costs, thus putting teaching institutions
at risk. Further, this attempts to shift the burden
of educational costs to government payers like Medicare,
and the Department of Veterans Affairs Healthcare System
at a time when their resources are being reduced.
Medicaid
represents a federal-state partnership that delegates
management authority to each state. The current practices
for supporting graduate medical education vary widely.
For example, New York State provides $500 million annually,
whereas California does not use its Medicaid funds in
this manner. Thirty-seven of the 50 states do contribute
to graduate medical education support. Since private
payers have not isolated the educational support, the
costs are distributed as a part of the gross premium.
In most states private payers pay a higher premium to
teaching hospitals as a means of supporting graduate
medical education.
Capitated
care, which is becoming increasingly widespread, has
a definite impact on academic cardiology, even though
an academic cardiology unit may have several intrinsic
advantages over a nonacademic system. The main advantage
is perceived quality of care, which, according to the
Healthcare Advisory Board, is the single most powerful
tool for attracting cardiac admissions and for building
program volume. Thus, important factors in operating
a successful academic cardiology program include the
presence of high quality physicians, the presence of
a physical plant with state-of-the-art facilities, a
commitment to research which ensures access to state-of-the-art
devices and the availability of investigational drugs.
In
summary, it appears that the nation and most state governments
are prepared to support graduate medical education at
a reduced level, but in return, will demand more accountability
for the expenditures and require that emphasis on specialization
and academic development be balanced with programs designed
to support "public goods." In the current
era, these usually are represented by a need to increase
the output of generalists, to reduce the output and
distribution of selected specialists, to redistribute
patient care and medical education to ambulatory care
and other community sites and to increase the representation
of minority and other socially disadvantaged populations
in the medical profession.
For
academic cardiology, these changes need not portend
a loss of its stature, importance or survival. Rather,
academic cardiology is recognized and appreciated for
its many tremendous accomplishments, credibility and
visibility. Thus, it has an opportunity to position
itself to use its talented workforce to integrate better
the continuum of patient care, research and education
through a network or system that incorporates the resources
of the core academic center, ambulatory care sites (urban
and rural) and appropriate community health care sites.
Academic cardiology, of all of the medical subspecialties,
is probably better prepared and able to respond to the
evolving changes in medical education than are most
other medical subspecialties.
CONCLUSIONS
Effective
teaching is fundamentally important to the future of
academic cardiology. Recent changes in the delivery
of health care have had major impact on the capability
of clinician-educators to function as effective teachers.
This has occurred in the setting of increasing complexity
of the specialty which in itself mandates the need for
high quality teachers with sufficient time to impart
new information and techniques. Innovative strategies
will be required to resolve this problem.
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