Hanging Together

Straight Talk | We physicians are a highly educated but fiercely independent lot. Through that education, we become comfortable that medical knowledge itself is in continuous evolution, sputtering forward in fits and starts, the ebb and flow of new ideas part of the rhythm of our lives. We use that education to subjugate our more independent character, allowing us as a group to agree on a direction forward all the while realizing that more information will be forthcoming and the rules we agree upon may change.

In these instances the collective "we" has little difficulty grasping the changes and moving forward, embedding the knowledge evolution into our body politic and subsequently the daily care we provide.

Our ability to achieve such a unified mindset, however, is woefully lacking when confronted with the external social, political and economic forces that currently surround us. In this arena our education is deficient and our independent character moves to the fore, overwhelmingly to our detriment.

In reality, these external forces impacting medicine, jarring our sense of control and unilaterally altering our profession, have reduced us to petty squabbling amongst ourselves, a situation the forces arrayed against us use to great advantage. Composed of an assemblage of legislative and regulatory bodies, they claim to be attempting to improve the more global healthcare environment but, to us, appear to simply impede our care delivery, either directly by dictating the environment of care or indirectly by diverting our attention from such care. Our response, both individually and collectively through our professional organizations, is fragmented, divergent, sometimes even diametrically opposed, rendering that rejoinder impotent and easily dismissed by others.

Physician integration, the scope of non-physician practice and the maintenance of certification serve as examples.

Recent reimbursement reductions, beginning with the 2010 physician fee schedule (ostensibly to help balance the differences between cognitive and procedural reimbursement) resulted in the mass migration of cardiologists to hospital employment, creating issues of increased patient co-payment and, as predicted, greatly increased cost to the healthcare system itself. Within cardiology, we now face such conundra as site-neutral payment, and of the disparate needs of employed, private, and academic physicians, which is fracturing the profession and impeding any effort to resolve our innate problems, much less engage in meaningful dialogue with these very external organizations and regulatory agencies.

The projected shortage of physician providers has inflamed the discussion regarding the scope of practice of non-physician providers to a fever pitch. With no shortage of opinions on all sides, cardiologists and the myriad of non-physician providers on our care teams (with whom we work daily) are finding difficult the juxtaposition of the concept of the provision of care by "the care team" with the actual roles and authority with which we enfranchise those members. At a broad level, this has evolved into not just a discussion of the role of advanced nurse practitioners in internal medicine and her sub-specialties, but also that of chiropractors in orthopedics, optometrists in ophthalmology and physical therapists in physical medicine and rehabilitation.

Modification in the Maintenance of Certification (MOC) requirements, unilaterally implemented by the American Board of Internal Medicine (ABIM) in response to the American Board of Medical Specialties (ABMS)/Accreditation Council for Graduate Medical Education (ACGME) desire to assure proficiency in their self-determined six core competencies, has sparked outrage in the broad provider community, internecine fighting amongst ABIM participants in particular and, through this, a lack of a unified response to the MOC issue itself. It is currently possible to find substantial factions in the cardiovascular community who want the secure examination to go away in favor of a more continuous open-book process, as well as those who want only the secure examination with no inter-current requirements at all. The response of those external to us, those responsible for the change is, predictably, confused and hesitant.

Our steps forward should be simple and direct, yet in their simplicity lays our greatest challenge—for in addressing them we must first overcome our greatest weakness, our independent nature.

First, we must understand, internalize and accept that each of us is experiencing loss. Whether that loss is monetary, temporal, or even the loss of control of our own destiny, it is real and will not be recaptured. We as a species do not fear change, we fear loss; we as a profession abhor loss, viewing it as failure. There is, however, no going back. In understanding our losses, cooperative behavior becomes possible, a way forward more clear.

Second, we must engage and educate our colleagues—that broad body of cardiologists—in the nuances of the issues that exist. More importantly, we must teach them that participation in the group effort itself leads to success; for it is with this participation that isolationist thinking and individualism recede such that broad internal consensus may be molded.

Third, when internal consensus is reached, we must present that unified front to our leaders, both within medicine and without, using it to drive meaningful change.

Until we do so, until our individualism gives way to cooperative dialogue, the piecemeal dismantling of our profession will continue.

As is often heard in Washington, "If you're not at the table, you're on the menu!"

Keywords: ACC Publications, CardioSource WorldNews

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